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THE   SYSTEMATIC   TREATMENT 
OF  GONORRHOEA 


THE 


SYSTEMATIC  TREATMENT 


OF 


GONORRHCEA 


BY 

N.  P.  L.  LUMB 

TEMP.    CAPT.    R.A.M.C. 


LEA   &    FEBIGER 

PHILADELPHIA   AND   NEW  YORK 

1918 


S\    fi     »)    ,v     o 


[Printed  in  England] 


PREFACE 

The  commencement  of  an  official  campaign  against 
Venereal  Disease  has  led  to  the  production  of  this  book. 
Many  of  those  assisting  at  Treatment  Centres  may  have 
had  little  opportunity,  in  the  past,  of  gaining  experience 
of  this  work,  and  for  such  it  is  intended. 

It  was  planned  more  than  a  year  ago  with  the  object 
of  providing  a  small  volume  which  should  contain  a 
description  of  the  methods  which  are  found,  in  practice, 
to  be  most  valuable  in  the  treatment  of  gonorrhoea 
and  its  complications.  Active  service  conditions  have 
considerably  delayed  its  production  and  somewhat 
limited  its  scope ;  but,  throughout,  the  aim  has  been 
to  give  practical  details  of  methods  which  have  been 
fully  tested  in  many  thousand  cases  with  satisfactory 
results. 


CONTENTS 

CHAPTER   I 

PAGE 

GONORRHOEA,  ITS  COURSE  AND  SYMPTOMS  :    HISTORY, 

DIAGNOSIS    AND   EXAMINATION         ...  I 

CHAPTER    II 

PATHOLOGY  AND   BACTERIOLOGY  ...         10 

CHAPTER   III 

EXAMINATION   OF   THE    URINE        .  .  15 

CHAPTER   IV 

EXAMINATION    OF   THE    PROSTATE;    ACUTE  PROSTA- 
TITIS,   CHRONIC   PROSTATITIS  ...         23 

CHAPTER   V 

ROUTINE   TREATMENT  OF  ACUTE   GONORRHOEA  .         38 

CHAPTER   VI 

SPECIAL  TREATMENTS:     I.    VACCINE.      2.    ELECTRO- 
CHEMICAL.     3.    MERCURY  COMPOUNDS     .  .         44 

vii 


viii  CONTENTS 

CHAPTER   VII 

PAGE 

COMPLICATIONS  OF  GONORRHOEA:  EPIDIDYMITIS, 
ARTHRITIS,  COWPERITIS,  PERI- URETHRAL 
ABSCESS       .  .  .  .  .  .  .58 

CHAPTER   VIII 

GONORRHEAL  CONJUNCTIVITIS      ....         73 

CHAPTER   IX 

GONORRHOEA  CASES  COMPLICATED  BY  SYPHILIS       .         80 

CHAPTER   X 

CHRONIC  GONORRHOEA 87 

CHAPTER   XI 

THE   GONORRHOEA  PATIENT — TEST  OF  CURE        .      .       1 10 

INDEX .         .     117 


THE 

SYSTEMATIC  TREATMENT 
OF  GONORRHOEA 

CHAPTER    I 

GONORRHOEA  :     ITS   COURSE   AND   SYMPTOMS 

Until  recent  years  this  disease  has  never  received  the 
attention  it  demands  by  reason  of  its  ravages  when 
widespread.  Now,  however,  with  a  scheme  afoot,  and, 
in  many  places,  working,  for  the  provision  of  skilled 
and  adequate  treatment  for  all  classes  there  is  a 
hope  of  new  and  improved  methods  being  widely 
adopted. 

Two  facts  need  to  be  made  as  widely  known  as  possible 
for  the  benefit  of  all  who  may  be  sufferers  from  the 
disease : 

(i)  Early  treatment  means  early  cure. 

(2)  "  Gleet  "  is  an  infectious  condition,  and  needs 
treatment  just  the  same  as  an  acute  case. 

It  can  be  proved  time  and  again  that  a  patient  obtain- 
ing correct  treatment  within  the  first  twenty-four  to 
forty-eight  hours  of  the  discharge  will,  in  the  majority 
of  instances,  develop  no  complications  and  will  need  the 
shortest  time  on  treatment.     A  good  result  is  to  be  hoped 

1 


2  TREATMENT   OF  GONORRHOEA 

for  from  the  venereal  treatment-centres  mainly  for  this 
reason. 

To  get  patients  to  attend  systematically  for  treat- 
ment for  gleet  will  be  more  difficult,  but  increased  know- 
ledge and  an  enlightened  public  will  help  considerably 
in  this  respect. 

The  organism  causing  the  disease,  Neisser's  Gono- 
coccus,  has  been  dealt  with  under  the  chapter  on 
pathology  and  bacteriology  of  the  disease.  Once  the 
gonococcus  has  been  implanted  on  the  urethral  mucous 
membrane  events  follow  in  a  definite  sequence.  The 
incubation  period  begins,  and  during  this  time  the 
organisms  are  multiplying  and  extending  beneath,  as 
well  as  along,  the  surface.  The  rate  of  progress  depends 
upon  two  variable  factors  : 

(a)  The  virulence  of  the  infecting  gonococcus. 

(b)  The  resistance  of  the  urethral  mucosa. 

Thus  it  is  that  a  common  source  of  infection  will 
lead  to  attacks  of  varying  severity  in  different  indi- 
viduals, some  developing  complications  and  others 
having  only  the  mildest  manifestations.  The  usual 
course  may  be  briefly  indicated.  Following  on  infection 
the  gonococcus  is  free  to  develop.  An  interval  occurs 
between  the  exposure  and  the  appearance  of  any  symp- 
toms. This  incubation  period  varies  and  may  be  as 
short  as  two  days  or  as  long  as  a  month.  The  majority 
of  patients  give  seven  days  as  the  interval  before  the 
appearance  of  a  discharge.  The  first  warning  that  all 
is  not  as  it  should  be  is  frequently  a  sensation  of  warmth 
and  tickling  in  the  urethra,  intensified  after  mictu- 
rition. This  increases  gradually  until  a  distinct 
burning  is  perceptible  and  the  tickling  becomes  actual 
discomfort. 

Micturition    causes     definite    smarting    and,    later, 


ITS   COURSE  AND   SYMPTOMS  3 

pain.      Frequency    creeps    on    pari    passu    with    the 
pain. 

The  first  visible  sign  of  the  disease  is  an  increase  of 
moisture  at  the  meatus,  noticed  by  the  patient  on  rising 
in  the  morning,  which  often  glues  the  lips  together. 
From  this  stage  onwards  the  secretion  becomes  more 
and  more  characteristic,  until,  twenty-four  hours 
later,  there  is  usually  a  definite  purulent  discharge.  The 
pain  becomes  more  acute  on  micturition  and  remains  for 
a  considerable  period  after  the  act.  The  whole  urethra 
is  tender  when  touched,  and  the  lips  of  the  meatus  are 
red  and  swollen.  In  severe  cases  the  prepuce  becomes 
more  swollen  and  cedematous,  quite  apart  from  the 
presence  of  any  sore.  Chordee  increases  the  discomfort, 
the  penis  being  drawn  downwards  owing  to  the  infiltra- 
tion of  the  urethra  and  the  consequent  loss  of  its  normal 
elasticity.  Following  on  these  attacks  blood  is  frequently 
seen  either  at  the  meatus  or  on  subsequent  micturition. 
Painful  erections  occur  at  night,  diminishing  the  patient's 
sleep  and  often  accompanied  by  seminal  emissions.  The 
lymphatic  nodes  in  the  groin  become  enlarged  and 
slightly  tender.  In  a  small  percentage  of  cases  they  are 
exceedingly  painful  from  the  start  and  continue  so  for 
several  days,  necessitating  hot  fomentations  and  rest  in 
bed.  In  the  absence  of  soft  sores  suppuration  does  not 
occur. 

The  general  condition  of  the  patient  corresponds 
with  the  mild  febrile  attack  which  always  accompanies 
the  onset  of  symptoms,  and  resembles  the  beginning 
of  an  ordinary  cold.  The  temperature  varies  between 
990  and  100 °,  there  is  a  feeling  of  lassitude,  aggravated 
by  the  discomfort  and  frequency  of  micturition.  Con- 
stipation is  common.  The  discharge  increases  until 
there  is  an  almost  continuous  flow  of  thick  yellowish- 


4  TREATMENT   OF  GONORRHCEA 

green  pus.     Patients  have  usually  reached  this  stage 
before  coming  for  treatment. 

Three  distinct  types  can  be  recognized  in  the  acute 
stage  according  to  the  severity  of  the  invasion  and  the 
patient's  natural  resistance  to  the  infection  : 

(a)  Hemorrhagic. 

(b)  Acute. 

(c)  Mild. 

Hemorrhagic. — In  this  type,  the  invasion  is  very  severe 
and  most  often  seems  to  occur  in  the  individual  of  florid 
type.  Presumably  the  resistance  is  less  than  in  the 
majority  of  patients.  There  are  intense  pain  on  micturi- 
tion and  considerable  swelling  of  the  glans  and  prepuce. 
Every  symptom  seems  to  be  present  in  an  aggravated 
form.  The  discharge  is  thick,  profuse,  purulent,  and 
mixed  with  blood.  It  can  be  found  at  any  time  by 
massage  of  the  urethra,  and  frequently  a  few  drops  of 
pure  blood  follow.  The  tenderness  of  the  whole  urethra 
is  extreme.  Fortunately  these  cases  are  not  numerous, 
and  respond  quite  readily  to  treatment. 

Acute. — This  is  the  commonest  variety,  where  the 
symptoms  are  very  much  as  already  described.  There 
are  pain,  frequency  of  micturition,  and  a  free  dis- 
charge. 

Mild. — A  certain  number  of  cases  developing  an 
acute  attack  of  gonorrhoea  show  very  slight  manifesta- 
tions. The  discharge  is  never  profuse,  little  discomfort 
is  experienced  on  micturition,  and  the  urethra  is  not 
tender  to  the  touch.  Yet  a  film  taken  from  the  meatus 
in  the  morning  shows  the  typical  acute  picture,  with 
pus-cells  containing  numerous  gonococci.  These  cases 
often  tend  to  subside  spontaneously  without  treatment, 


ITS  COURSE  AND   SYMPTOMS  5 

the  secretion  amounting  to  little  more  than  a  morning 
bead  four  or  five  days  after  the  onset.  If  no  treatment 
be  carried  out  the  discharge  rarely  disappears  com- 
pletely, and  the  patient  may  seek  advice  when  the  acute 
stage  has  passed  off.  The  importance  of  these  cases 
lies  in  the  fact  that  a  cursory  examination  may  lead  to 
the  patient  being  told  that  he  has  not  got  gonorrhoea, 
and,  should  inadequate  treatment  be  given,  he  is  liable 
at  a  later  date  to  develop  epididymitis  or  to  pass  into 
the  chronic  stage.  When  large  numbers  are  dealt  with 
many  cases  of  acute  epididymitis  are  seen  in  whose  urine 
the  gonococcus  is  readily  found,  but  who  are  confident 
that  they  have  never  had  gonorrhoea.  The  possibility 
of  recent  infection  can  be  excluded  in  many,  leaving  a 
number  who  have  had  gonorrhoea  without  appreciating 
the  fact.  Such  cases  usually  belong  to  the  type  just 
described. 

Once  treatment  of  the  disease  is  commenced,  the 
symptoms  speedily  abate,  the  discharge  becomes  thinner 
and  less  in  quantity,  and  the  pain  on  micturition 
diminishes.  The  initial  pyrexia  passes  off,  the  general 
condition  rapidly  improves,  until,  a  week  after  the  com- 
mencement, the  patient  feels  perfectly  well,  and  should 
be  going  about  as  usual.  Complications  occur  in  a 
certain  proportion  which,  in  the  past,  has  been  high  ; 
but,  with  earlier  treatment  and  improved  methods,  the 
number  should  be  considerablv  diminished. 


HISTORY,    DIAGNOSIS,    AND    EXAMINATION 

Case-recording  of  gonorrhoea  patients  needs  to  be 
done  systematically,  both  from  the  point  of  view  of  treat- 
ment, and  also  the  obtaining  of  statistics  as  to  the 
efficacy  of  different  methods  of  treatment.     The  latter 


6  TREATMENT   OF  GONORRHOEA 

have  improved  considerably  in  recent  years,  yet  even 
now  it  is  unwise  to  promise  to  effect,  a  lasting  cure  in  any 
case.  From  experience  of  a  large  series  it  is  found  that 
a  considerable  percentage  of  such  cases  have  no  return 
of  symptoms ;  yet  time  alone  shows,  and  there  is,  at 
present,  no  test  at  all  comparable  with  the  Wassermann 
Reaction  in  Syphilis  to  guide  the  surgeon  as  to  his 
patient's  future  outlook.  The  history  of  a  patient 
regarding  past  illness  has  little  bearing  on  his  sub- 
sequent treatment  for  venereal  disease,  but  may  give  an 
idea  of  his  power  to  resist  or  throw  off  an  infection.  The 
venereal  history,  however,  should  be  gone  into  carefully 
and  any  previous  attacks  noted.  Not  infrequently  a 
history  of  past  syphilis  or  a  doubtful  sore  may  be  ob- 
tained, and  this  information  should  lead  to  a  blood-test 
and  suitable  treatment  if  it  prove  positive.  In  gonorrhoea 
the  date  and  duration  of  previous  attacks  should  be 
recorded,  and  also  complications  or  relapses,  if  any. 
The  incubation  period  of  a  recent  infection,  together 
with  the  patient's  age,  often  afford  information  of  value. 
The  actual  date  on  which  the  disease  was  contracted 
should  be  obtained- whenever  possible,  so  that  the  onset 
of  syphilis  may  not  be  overlooked  in  its  early  stages  if 
a  double  infection  have  taken  place. 

Diagnosis. — The  diagnosis  is  usually  a  simple  matter, 
though  occasionally,  in  the  absence  of  a  clear  history 
of  exposure  to  infection  and  subsequent  development 
of  the  usual  clinical  signs,  reference  to  the  microscope 
is  necessary.  It  must  not  be  forgotten  that  a  non- 
gonococcal urethritis  may  very  occasionally  be  present, 
simulating  gonorrhoea.  Its  incubation  period  is  similar, 
but  microscopic  examination  readily  distinguishes  the 
two,  the  non-gonococcal  variety  being  usually  produced 
by  a  diplo-bacillus  or  staphylococcus  albus, 


ITS   COURSE  AND   SYMPTOMS  7 

When  balanitis  is  present  it  may  be  quite  impossible 
to  say  at  once  whether  a  patient  is  suffering  from  gonor- 
rhoea, owing  to  the  profuse  discharge  from  beneath  the 
prepuce.  If  the  urethritis  be  in  the  acute  stage,  it  may 
be  possible,  after  cleansing  the  glans,  to  express  pus  from 
the  urethra,  but  failing  this  no  final  opinion  should  be 
expressed,  for  microscopically  Gram  negative  diplococci 
can  be  found  in  both  conditions.  The  subjective  test 
of  smarting  during  micturition  is  not  a  safe  guide,  many 
cases  of  simple  balanitis  complaining  of  it  owing  to  sore- 
ness of  the  glans.  Local  baths  several  times  daily  with 
syringing  will  usually  enable  the  prepuce  to  be  retracted 
and  the  discharge  cleared  up.  A  two-glass  urine  test 
can  then  be  made,  and,  if  necessary,  a  smear  taken  for 
microscopic  examination.  Occasionally  some  difficulty 
may  arise  in  distinguishing  between  a  gleet  and  the 
exudation  from  a  urethral  chancre.  A  patient  may 
give  a  history  of  gonorrhoea  some  months  previously, 
and  then  the  appearance  of  a  small  amount  of  glairy 
discharge  a  little  while  after  re-exposure  to  infection. 
The  incubation  is  usually  uncertain,  and  the  stage  of 
development  too  early  for  a  Wassermann  Reaction  to 
settle  the  matter  finally.  A  chancre,  if  present,  is 
usually  palpable  in  the  urethra,  and  most  of  them  are 
situated  within  an  inch  of  the  meatus.  In  such  cases  a 
scraping  and  dark-ground  examination  should  be 
made.  Failing  this,  the  urethroscope  will  reveal  a 
chancre  lower  down  the  urethra,  whilst  microsco- 
pically the  gonococcus  is  usually  to  be  seen  in  a  case 
of  gleet. 

Examination. — The  patient  should  be  examined  lying 
down  wherever  possible,  for  thereby  more  accurate  and 
extended  observations  can  be  made,  and  there  is  much 
more  inducement  to  investigate  thoroughly.     A  system 


8  TREATMENT  OF  GONORRHOEA 

should  be  adopted  and  adhered  to,  just  as  in  the  case  of 
the  examination  of  the  chest  or  central  nervous  system, 
so  that  a  correct  record  of  all  cases  may  be  obtained  and 
important  signs  not  overlooked.  A  useful  plan  is  the 
following  :  Commence  by  palpating  the  groins  and  noting 
the  condition  of  the  inguinal  glands  as  regards  size, 
tenderness,  and  the  presence  of  suppuration.  A  very 
good  guide  as  to  the  condition  present  is  thus  obtained. 
In  gonorrhoea  they  are  moderately  enlarged,  though  but 
slightly  tender,  both  sides  being  equally  involved. 
In  some  cases  of  acute  gonorrhoea,  however,  these  glands 
(usually  of  one  groin)  become  very  painful,  though  the 
enlargement  is  but  moderate,  the  pain  being  referred 
upwards  along  the  cord  and  down  the  inner  side  of 
the  thigh.  In  soft  chancre  the  glands  are  considerably 
enlarged,  tender  and  characteristic  buboes  are  frequently 
seen.  In  syphilis  the  enlargement  is  usually  more  than 
in  gonorrhoea,  and,  often,  one  groin  is  affected  more 
markedly  than  the  other.  The  glands  feel  hard  and  move 
freely  under  the  skin,  whilst  there  is  a  complete  absence 
of  tenderness  or  suppuration.  The  whole  of  the  group 
is  usually  affected,  and  can  be  felt  as  an  indolent  chain 
extending  outwards  along  Poupart's  ligament.  When 
a  double  infection  is  present  the  glands  combine  features 
of  both,  and  are  not  so  useful  in  diagnosis.  The  prepuce 
is  next  retracted,  the  glans  and  meatus  being  wiped 
free  from  any  accumulated  discharge  with  small  swabs 
of  cotton-wool  wrung  out  of  i  in  1,000  perchloride  of 
mercury.  The  corona  and  fraenum  are  carefully  in- 
spected for  the  presence  of  a  sore,  then  the  lips  of 
the  meatus  separated  so  that  a  meatal  chancre,  which  is 
not  uncommon,  may  not  be  overlooked.  The  urethra 
is  then  massaged  and  the  discharge  seen,  its  character 
being  noted  as  purulent,  muco-purulent,  or  gleet.    After 


ITS  COURSE  AND   SYMPTOMS  9 

this  the  epididymis  is  palpated  on  both  sides  to 
discover  if  there  be  any  enlargement  or  tenderness. 
In  cases  in  which  complications  have  already  super- 
vened when  the  patient  is  seen  for  the  first  time  the 
possibility  of  lesions  of  prostate,  joints,  ej/es,  and  skin 
must  not  be  forgotten. 


CHAPTER   II 

PATHOLOGY   AND    BACTERIOLOGY 

The  pathology  of  gonorrhoea  can  be  considered  very 
simply  under  three  headings  : 

(i)  The  incubation  period. 

(2)  The  acute  stage. 

(3)  The  chronic  stage. 

During  the  incubation  period  the  invading  organism — 
the  gonococcus — is  spreading  from  its  site  of  implantation 
within  the  meatal  area  in  two  directions :  (a)  Along  the 
surface  of  the  urethra  towards  the  bladder,  (b)  Between 
the  columnar  cells  lining  the  urethra  towards  the  sub- 
epithelial connective  tissue.  The  rate  of  spread  in  both 
cases  depends  entirely  upon  the  virulence  of  the  organism 
implanted  and  the  natural  resistance  of  the  patient.  It 
is  unusual  for  penetration  of  the  surface  to  take  place  in 
less  than  forty-eight  hours.  Following  on  this,  the 
gonococci  work  their  way  down  between  the  interstices 
of  the  cells  until  they  begin  to  come  in  contact  with 
leucocytes,  chiefly  polymorphonuclear,  poured  out  from 
the  capillaries  to  counter  the  invasion  of  the  organisms. 
The  result  is  that  many  gonococci  are  taken  up  in  the 
leucocytes,  which  travel  to  the  surface  and  are  cast  off 
as  pus- cells,  giving  rise  to  the  purulent  discharge.  The 
effect  of  the  passage  of  gonococci  and  leucocytes  is  to 

jo 


PATHOLOGY  AND  BACTERIOLOGY    n 

break  up  the  epithelial  lining  of  the  urethra  and  desqua- 
mation in  numerous  areas  results.  With  the  appearance 
of  a  discharge  the  incubation  period  ends  and  the  acute 
stage  begins.  The  rate  of  extension  along  the  surface 
cannot  be  determined  accurately,  but  it  must  be  rapid, 
for  statistics  show  that  in,  roughly,  70  per  cent,  of  cases 
the  organisms  reach  the  posterior  urethra. 

Acute  Stage. — This  is  a  continuation  of  the  struggle 
between  the  leucocytes  and  the  gonococci,  and,  in  addi- 
tion, an  extension  of  infection  to  the  lacunar  and  glands 
of  Littre.  The  organisms  lie  between  the  cells  sur- 
rounding theglandmouthsand  lead  to  one  of  two  changes: 
either  sclerosis,  with  eventual  obliteration  and  atrophy 
of  the  gland,  or  obstruction  of  the  duct  by  cast-off 
epithelial  cells  and  subsequent  cyst-formation. 

In  the  posterior  urethra  the  process  is  exactly  the  same 
as  in  the  anterior  portion,  but,  as  a  result  of  the  greater 
delicacy  and  increased  vascularity,  even  a  small  denuda- 
tion of  the  surface  frequently  leads  to  haemorrhage.  As 
the  invasion  is  gradually  overcome  by  treatment  repair 
of  the  epithelial  surface  begins,  and  cylindrical  cells 
cover  the  desquamated  areas.  Eventually  the  columnar 
epithelium  is  restored  in  many  instances,  but,  as  will  be 
•seen,  where  prolonged  inflammation  has  occurred  this 
condition  is  not  fulfilled  and  secondary  changes  occur. 

Chronic  Stage. — The  tissue-reaction  has  practically 
subsided,  and  there  is  no  longer  a  great  outpouring  of 
leucocytes,  whilst  the  gonococci  are  comparatively  few 
in  number.  To  replace  the  epithelial  lining  several  layers 
of  pavement  epithelium  develop,  thus  giving  rise  to  a 
more  resistant  and  less  delicate  surface  than  was  the 
case  before  the  infection.  In  the  case  of  the  glands  the 
organisms  remain  indefinitely,  deep-seated,  and  difficult 
to  eradicate,  yet  liable  to  appear  on  the  surface  at  any 


12     TREATMENT  OF  GONORRHOEA 

subsequent  period,  rendering  the  patient  a  constant 
source  of  infection.  As  the  infiltration  around 
the  glands  subsides  three  different  changes  may 
occur  : 

(i)  The  lining  of  the  duct  is  shed  and  may  give  rise 
to  a  discharge  from  the  gland  mouth. 

(2)  The  gland  itself  becomes  surrounded  by  newly 
formed  tissue,  and  is  destroyed  by  the  gradual  contraction 
of  the  latter. 

(3)  The  duct  becomes  occluded  and  the  gland  con- 
tents are  shut  in,  leading  to  cyst-formation. 

An  outline  only  has  been  given,  with  the  object  of 
indicating  the  changes  which  are  of  importance  from  the 
treatment  point  of  view. 

Keratinisation  and  the  developments  leading  to 
stricture-formation  are  not  discussed,  since  it  is  not 
intended  to  deal  with  this  aspect  of  the  subject  in  the 
space  at  disposal. 

Bacteriology 

The  causative  organism  of  gonorrhoea  is  Neisser's 
gonococcus,  a  diplococcus  and  Gram-negative.  It  is 
readily  found  in  smears  taken  from  the  urethra  in  acute 
cases,  and  can  be  easily  identified. 

Smears  of  a  discharge  for  microscopic  examination 
should  be  taken  as  follows  :  The  prepuce  is  retracted 
and  the  glans  wiped  over  with  a  swab  of  wool  moistened 
with  methylated  spirit,  special  attention  being  paid  to 
the  lips  of  the  meatus,  which  are  separated  and  freed  from 
all  discharge.  The  urethra  is  then  gently  compressed 
until  a  small  bead  appears,  when  a  drop  of  this  is  re- ' 
moved  from  within  the  lips  of  the  meatus  on  a  platinum 
loop  and  transferred  to  a  slide.  If  very  thick,  a  small 
drop  of  water  is  next  added,  so  as  to  enable  an  even  film 


PATHOLOGY   AND   BACTERIOLOGY         13 

to  be  spread.  This  is  fixed  by  passing  a  few  times 
through  the  flame  of  a  spirit-lamp  and  stained  by  Gram's 
method.  By  careful  cleansing  of  the  glans  and  prepuce 
beforehand  all  contamination  is  avoided  and  the  organ- 
isms of  balanitis,  which  at  times  lead  to  confusion,  are 
removed. 

Urine. — To  be  tested  for  gonococci.  If  any  threads 
or  filaments  are  present  they  are  removed  by  means  of  a 
fine  glass  pipette  and  transferred  to  a  slide,  teased  out  well 
with  a  platinum  loop,  fixed  and  stained  as  in  the  case 
of  smears.  The  bulk  of  the  specimen  is  allowed  to  stand 
for  an  hour  and  then  a  few  c.cs.  taken  from  the  bottom 
of  the  glass  with  the  pipette.  This  is  centrifuged  and 
two  or  three  drops  spread  out  on  a  slide  and  allowed  to 
dry  slowly.  It  is  finally  fixed  by  heat  and  then  a  little 
distilled  water  placed  on  the  slide  and  allowed  to  remain 
for  five  minutes.  This  clears  the  film  considerably  by 
dissolving  out  the  salts  in  the  urine.  The  distilled 
water  is  poured  off  and  staining  proceeded  with  in  the 
ordinary  way. 

Prostatic  Smears. — After  thorough  irrigation  of  the 
urethra  the  meatus  is  wiped  over  with  spirit.  The 
prostate  is  then  massaged  in  the  ordinary  manner  and 
one  or  two  drops  of  secretion  allowed  to  fall  on  a  slide. 
This  is  spread  out  by  means  of  a  platinum  loop,  dried, 
and  stained. 

In  the  early  acute  stage  the  film  shows  epithelial  cells, 
pus-cells,  and  numerous  gonococci,  both  intra-cellular 
and  extra-cellular.  As  the  acute  stage  becomes  fully 
developed  the  epithelial  cells  disappear  and  the  field 
contains  nothing  but  pus  and  gonococci.  There  are, 
frequently,  many  Gram-positive  organisms  present  in 
the  film,  but  with  careful  staining  they  are  easily  dis- 
tinguished.    As  the  infection  is  overcome  and  healing 


14    TREATMENT  OF  GONORRHCEA 

is  once  more  in  progress  epithelial  cells  begin  to  appear 
again,  the  pus  cells  and  gonococci  being  much  reduced 
in  number. 

In   prostatic   smears   the   gonococci   are,   often,   not 
numerous  and  need  to  be  searched  for  carefully. 


CHAPTER   III 

EXAMINATION   OF   THE    URINE 

The  systematic  examination  of  the  urine  is  the  most 
useful  guide  available  in  estimating  the  progress  of  a 
case  of  gonorrhoea,  and  for  that  reason  alone  should 
take  a  prominent  place  during  treatment ;  but  it  is 
also  of  considerable  value  in  diagnosis.  When  a  case 
comes  under  observation  for  the  first  time  the  urine 
should  invariably  be  examined  in  the  manner  described, 
since  a  far  more  correct  view  of  the  extent  of  the  infection 
will  thereby  be  formed. 
For  diagnostic  purposes  the  most  useful  methods  are  : 

(i)  Two-glass  method. 
(2)  Four-glass  method. 

An  acute  case,  on  first  coming  for  treatment,  should  be 
instructed  to  pass  a  two-glass  sample  of  urine  on  rising. 
Six  to  eight  ounces  of  urine  are  passed  into  one  glass  and 
the  last  few  ounces  in  the  bladder  into  the  second  glass. 
The  urine  that  has  collected  during  the  night  is  far  more 
valuable  than  that  of  several  hours  in  the  daytime,  and 
should  always  be  taken  as  the  standard  for  comparison. 
Such  a  two-glass  sample  will  show  signs  varying  with 
the  stage  to  which  the  disease  has  attained. 

Pus  secreted  into  the  anterior  urethra  cannot  pass 
back  into  the  bladder  because  of  the  compressor  urethrae 

15 


16     TREATMENT  OF  GONORRHOEA 

muscle,  but  it  is  free  to  pass  forward  (i.e.  anterior  to  it)  ; 
whilst  pus  in  the  posterior  urethra  cannot  pass  forward 
because  of  the  same  muscle,  but  is  free  to  pass  back  into 
the  bladder.  During  sleep  the  discharge  in  an  acute 
case  collects  in  the  anterior  portion  of  the  urethra  and 
some  of  it  flows  away.  In  the  posterior  urethra  it  passes 
backwards  and  mixes  with  the  urine  in  the  bladder. 

When  the  two-glass  test  is  made  the  first  glass  contains 
urine  from  the  bladder  which  has  washed  out  the  pus 
from  the  anterior  portion  of  the  urethra.  The  second 
glass  contains  the  last  contents  of  the  bladder  alone. 
Consequently,  the  first  glass  is  more  cloudy  than  the 
second.  If  both  glasses  are  cloudy  the  whole  extent  of 
the  urethra  is  probably  involved,  i.e.  anterior  and 
posterior  urethritis.  If  the  first  is  cloudy  and  the  second 
clear,  the  anterior  urethra  alone  is  affected.  It  must  be 
recognized  that  this  is  a  rough  test,  and  is  to  be  inter- 
preted only  in  the  light  of  accompanying  clinical  signs — 
For  instance,  in  the  case  of  an  acute  attack  with  profuse 
discharge  it  is  frequently  found  that  in  the  early  stage 
both  glasses  are  cloudy,  though  glass  I  more  so  than 
glass  2.  It  does  not  necessarily  follow  that  there  is 
anterior  and  posterior  urethritis,  for  the  quantity  of 
urine  passed  in  such  a  test  is  often  insufficient  to  wash 
away  all  the  thick  pus  from  the  anterior  urethra,  and 
the  last  few  ounces  are  cloudy  with  pus  from  the  anterior, 
not  the  posterior,  urethra. 

It  will  readily  be  understood  that  the  second  glass  in 
samples  passed  during  the  daytime  will  be  clearer  than 
in  an  all-night  specimen,  for  there  is  less  opportunity 
for  pus  to  gravitate  from  the  posterior  urethra  into  the 
bladder  owing  to  the  change  of  posture  and  the  frequent 
emptying  of  the  bladder.  This  fact  must  be  remembered 
if  a  case  is  being  judged  on  a  specimen  passed  in  the 


EXAMINATION  OF  THE   URINE  17 

daytime.  In  addition,  it  serves  to  distinguish  cases  of 
cystitis,  for  in  the  latter  condition  the  second  glass  is 
just  as  cloudy  as  the  first  in  both  day  and  all-night 
samples. 

The  four-glass  test  differentiates  more  accurately 
the  state  of  the  anterior  and  posterior  urethra.  It  is 
carried  out  as  follows  : 

Three  or  four  ounces  of  urine  are  passed  into  Glass  1, 
and  then  two  ounces  into  Glass  2.  The  next  two 
ounces  are  passed  into  Glass  3,  and  the  last  few  ounces 
into  Glass  4. 

The  first  and  second  glasses  contain  the  washings 
of  the  anterior  urethra,  the  third  those  of  the  posterior, 
whilst  the  fourth  includes,  in  addition,  any  material  ex- 
pressed into  the  prostatic  urethra  by  the  terminal  con- 
traction of  the  prostate  at  the  end  of  micturition.  In  an 
early  acute  case  the  first  glass  is  usually  found  to  be 
cloudy,  the  second  also  cloudy,  but  less  so  than  the  first, 
whilst  the  third  and  fourth  are  quite  clear.  This  repre- 
sents anterior  urethritis  alone.  With  a  moderately 
severe  posterior  urethritis  in  addition,  all  four  are  cloudy. 
In  some  chronic  cases  all  four  glasses  may  be  more  or 
less  clear,  the  first  and  third  containing  a  few  flakes, 
the  second  and  fourth  none.  This  is  evidence  of  a 
localised  anterior  and  posterior  urethritis,  and  will  be 
referred  to  again.  The  four-glass  is  more  accurate  than 
the  two-glass  test,  but  to  obtain  the  most  satisfactory 
differentiation  of  the  affected  portions  of  the  urethra  the 
following  method  should  be  adopted  : 

The  anterior  urethra  is  irrigated  with  cold  boric  lotion 
at  a  pressure  of  two  feet.  This  will  not  pass  the  tri- 
angular ligament,  but  washes  out  any  material  collected 
anterior  to  it.  The  washings  are  collected  in  Glass  if 
the  glans  and  meatus  are  cleansed,  and  a  sterile  rubber 
2 


18     TREATMENT  OF  GONORRHCEA 

catheter  passed  into  the  bladder,  the  contents  of  the  latter 
being  collected  in  Glass  2.  Six  to  eight  ounces  of  warm 
boric  lotion  are  introduced  into  the  bladder  and  the 
catheter  withdrawn.  The  patient  passes  two  or  three 
ounces  of  this  into  Glass  3.  The  prostate  is  massaged 
and  the  remaining  five  or  six  ounces  of  lotion  are  passed 
into  Glass  4. 

Glass  1  represents  the  content  of  the  anterior 
urethra. 

Glass  2  that  of  the  bladder. 

Glass  3  represents  posterior  urethra. 

Glass  4  the  same  as  3,  with  the  secretion  of  the 
prostate-. 

This  is  a  very  accurate  method  ,of  locating  a  focus  of 
infection,  and  is  of  most  use  in  chronic  cases. 

For  treatment  purposes  the  two-glass  test  is  quite 
accurate  enough,  and  the  urine  should,  whenever  pos- 
sible, be  that  first  passed  on  rising.  This  test,  in  an 
acute  case  coming  for  treatment  with  a  history  of  dis- 
charge which  has  been  present  for  four  or  five  days, 
will  probably  show:  Glass  1,  cloudy;  Glass  2,  cloudy, 
though  less  so  than  1.  After  a  few  days'  treatment 
with  irrigations  and  vaccines  the  first  glass  becomes 
less  cloudy  and  the  second  more  or  less  clear,  depending 
on  the  success  with  which  the  irrigation  fluid  has  been 
flushed  through  into  the  bladder.  At  this  stage  the 
presence  of  flakes  or  filaments  is  not  important  from  the 
diagnostic  point  of  view,  but  after  about  ten  days'  treat- 
ment, when  the  first  glass  is  hazy  and  the  second  clear, 
their  presence  needs  careful  consideration.  Various 
names,  such  as  "  Sinkers  "  and  "  Floaters,"  have,  from 
time  to  time,  been  given  to  them,  according  to  whether 
they  sink  or  remain  suspended  in  the  test-glass.  For 
practical  purposes  five  varieties  need  to  be  recognized. 


EXAMINATION   OF  THE   URINE  19 

(i)  Littre's  gland  filaments. 

(ii)   Platelets. 

(iii)   Plugs  from  the  prostatic  ducts. 
(iv)  Muco-purulent  filaments. 

(v)  Threads. 

Their  respective  characteristics  are  as  follows  : 

(i)  Littre's  gland  filaments  are  readily  recognizable, 
being  light,  delicate,  and  of  a  well-curved  comma  shape, 
approaching  almost  to  a  semicircle.  After  the  passage 
of  a  straight  bougie  and  massage  of  the  glands  these 
filaments  are  readily  found  in  the  urine  next  passed,  in 
which  they  remain  suspended  for  a  time  and  then  sink 
slowly  to  the  bottom  of  the  glass. 

(ii)  Platelets  are  small  flakes  detached  from  the  sur- 
face of  the  urethra  that  remain  suspended  in  the  test- 
glass  for  some  time  and  sink  very  slowly  to  the  bottom. 
They  come  from  various  parts  of  the  urethral  surface 
where  the  urethritis  is  still  active.  They  are  quite  flat, 
and  the  name  of  "  bees'  wings,"  which  has  been  used 
to  describe  them,  is  not  inapt. 

(iii)  Plugs  from  the  prostatic  ducts  are  heavy  flakes 
which  sink  at  once  to  the  bottom  of  the  glass.  Like 
Littre's  gland  filaments,  they  are  comma-shaped,  but 
larger,  coarser,  and  less  curved. 

(iv)  Muco-purulent  filaments  consist  of  short  and 
narrow  lengths  of  the  mucosa  stripped  from  their 
attachments,  frequently  coiled  up  like  the  hair-spring 
of  a  watch.  They  cannot  be  confused  with  any  of  the 
other  varieties.  Sometimes  they  are  longer  and  more 
delicate,  looking  like  two  narrow  strips  held  together  by 
a  much  finer  intermediate  strip.  These  readily  break 
up  into  several  pieces,  even  as  they  sink  to  the  bottom 
of  the  test-glass. 


20     TREATMENT  OF  GONORRHOEA 

(v)  Threads  are  very  fine  filaments,  varying  con- 
siderably in  length,  of  the  same  nature  as  the  last  class, 
but  lighter.  They  often  persist  in  the  urine  for  some 
days  after  all  treatment  has  ceased  and  when  there  is  no 
evidence  of  discharge. 

Mucus.— The  presence  of  mucus  and  the  form  it 
assumes  is  a  very  important  guide,  in  addition  to  any 
filaments  there  may  be,  in  a  sample  of  urine.  In  the 
acute  stage  it  is  mingled  with  a  large  amount  of  pus  and 
is  not  distinctive  in  appearance  ;  but,  as  the  discharge 
becomes  less  profuse  under  treatment,  the  quantity  and 
form  can  be  clearly  seen.  After  five  or  six  days'  irrigation 
the  urine  in  the  first  glass  is  hazy,  resembling  frosted 
glass  when  looked  through,  the  mucus  still  being  diffused 
throughout  it.  Later  it  becomes  more  definite  in  form 
and  is  seen  as  a  dense  opaque  cloud  which  settles  on 
standing  for  half  an  hour.  It  frequently  occupies  the 
whole  of  the  lower  half  of  the  glass,  and  may  contain 
many  small  flakes  such  as  have  been  described  under  (ii) 
(Platelets).  As  treatment  continues  this  cloud  gradu- 
ally diminishes  in  size,  the  flakes  becoming  fewer,  until 
when  discharge  has  almost  ceased  and  the  mucosa  is 
approaching  normal,  all  that  is  seen  is  a  delicate  trans- 
lucent haze,  strongly  resembling  a  cumulus  cloud.  This 
is  frequently  suspended  in  the  glass,  unlike  the  dense 
earlier  cloud  which  sinks  to  the  bottom.  It  contains  no 
flakes,  and,  apart  from  being  slightly  more  profuse,  is 
identical  with  that  seen  in  normal  urine. 

Once  these  characters  are  clearly  recognized  it  is  an 
easy  matter  to  record  the  progress  of  any  case  under 
treatment,  and  to  form  a  correct  estimate  of  the  state 
of  the  urethra  and  the  glands  communicating  therewith. 

Case  1. — Incubation,  three  days.  Purulent  discharge, 
fifth  day  of  disease. 


EXAMINATION   OF  THE   URINE 


21 


Urine. 

Date. 

Irrigation. 

1. 

- 

" 

16-3-/ 

1  in  8,000  permg. 

Clear,  mucus,  m.p. 
filts. 

Clear 
Mucus 

Vaccine  2.  c.c. 

19-3-/ 

1/6000 

Clear,  mucus 

Clear 

Vaccine  4  c.c. 

22-3-/ 

1/6000 

Clear,  mucus 

Clear 

Vaccine  4  c.c. 

25-3-/ 

— , — 

Clear,  mucus,  two  pro- 
static filts. 

Clear 

Vaccine  4  c.c.  Si 
frequency 

29-3-/ 

Clear,  mucus,  one  pro- 
static flit. 

Clear 

Massage  of  Pr.  Some 
pus  and  normal 
secretion 

31-3-/ 



Clear,  s.m.p.  filts. 

Clear 

Vaccine  4  c.c. 

3-4"/ 

Clear 

Clear 

Vaccine 4 c.c.  P.Mas- 
sage.  A  trace  of 
muco-pus 

6-4-/ 

No  irrigation 

Clear 

Clear 

Vaccine  4  c.c. 

10-4-/ 

No  irrigation 

Clear 

Clear 

P.  Massage.  Normal 
secretion 

12-4-/ 

No  irrigation 

Clear 

Clear 

Case  2. — Incubation,  seven  days.    Purulent  discharge 
fourteenth  day  of  disease. 


Date. 

Irrigation. 

Urine. 

1. 

2. 

30-6-/ 

3-7-/ 
5-7-/ 

9-7-/ 

12-7-/ 

14-7-/ 

16-7-/ 
20-7-/ 

No  irrigation 

No  irrigation 

No  irrigation 
No  irrigation 

Clear,  much  mucus 
Clear,  mucous  cloud 
Clear,  cloud  of  phos- 
phates 
Clear,  s.m.p.  filts. 

(Platelets) 
Clear  very  few  s.m.p. 

filts. 
Clear 

Clear 
Clear 

Clear 
Clear 
Clear 

Clear 

Clear 

Clear 

Clear 
Clear 

2.  c.c. 

4.  c.c.  (2-7-/.) 

4.  c.c. 

4.  c.c. 

4  c.c. 

Pr.  Mass.  Pr.  not  enld. 
Normal  secretion 

These  two  cases  show  a  method  of  recording  the  urine  test  from  visit  to  visit, 
but  it  has  not  been  intended  to  show  a  complete  case  record.  The  above  is 
intended  merely  as  a  sample  and,  doubtless,  individual  methods  will  vary  as  they 
suit  the  convenience  and  mode  of  nomenclature  of  the  surgeon.  The  vaccine 
dosage  has  been  inserted  as  illustrating  the  method  advocated  in  the  chapter  on 
vaccine  treatment. 

In  estimating  progress  it  is  important  to  take  into 
consideration,  along  with  the  urine  test,  the  local  con- 
dition, i.e.  the  presence  of  a  discharge,  its   type  and 


22     TREATMENT  OF  GONORRHCEA 

quantity.  Without  this,  many  mistakes  in  treatment 
will  be  made.  For  instance,  when  prostatitis  has 
developed  in  a  case  under  treatment  with  permanganate 
irrigations,  frequently  the  urine  in  both  glasses  will  be 
quite  clear,  but  there  is  generally  a  little  purulent  or 
muco-purulent  discharge  to  be  found  on  massaging  the 
urethra  in  the  morning.  Judged  on  the  urine  test  alone 
such  a  case  would  be  considered  clear,  but  in  conjunction 
with  the  persistence  of  the  morning  bead  that  conclusion 
would  be  negatived  and  the  prostate  examined,  when 
pus  would  be  found,  and  suitable  treatment  adopted. 
Conversely,  at  the  onset  of  epididymitis  all  discharge 
will  frequently  disappear,  and  nothing  is  seen  in  the 
mornings  ;  yet  the  urine  generally  shows  a  peculiar 
cloudiness  in  both  glasses  and  a  tendency  to  deposit 
phosphates  very  readily,  the  latter  being  no  doubt  due 
to  the  developing  febrile  condition.  This  can  often  be 
noticed,  if  the  patient  be  under  regular  observation,  as 
long  as  forty-eight  hours  before  the  testicle  commences 
to  swell,  and  suitable  treatment,  administered  at  once, 
will  usually  assist  in  moderating  the  severity  of  the  onset. 
A  careful  consideration  of  clinical  signs,  together  with 
an  accurate  interpretation  of  the  urine-test,  will  enable 
the  treatment  of  any  case  to  be  carried  out  in  a  manner 
satisfactory  alike  to  patient  and  surgeon. 


CHAPTER   IV 

EXAMINATION    OF   THE    PROSTATE 

The  prostate  should  be  examined  in  every  case  of 
gonorrhoea  if  the  patient  is  to  have  the  best  possible 
prospect  of  freedom  from  relapse  when  treatment  has 
been  concluded.  The  exact  part  played  by  this  organ 
in  the  reappearance  of  a  discharge  some  long  time 
after  active  signs  have  disappeared  is  not  yet  evident, 
but  it  is  significant  that,  in  a  very  large  number  of 
such  cases,  the  prostate  is  found  enlarged  and  pus  is 
obtained  on  massage.  In  the  acute  case  this  gland 
becomes  infected  much  earlier  than  is  generally  believed, 
and  it  is  no  uncommon  thing  to  find  pus  formation  at 
the  end  of  the  first  week  of  the  attack.  This  being  so, 
it  becomes  necessary  to  know  at  what  stage  to  examine 
in  routine  treatment,  and  also  what  signs,  developing 
subsequently,  should  lead  to  further  investigation  of  the 
condition  of  the  prostate. 

Routine  Examination  is  best  done  after  the  patient 
has  been  under  treatment  for  a  week  or  ten  days,  except 
in  cases  of  acute  prostatitis,  which  require  to  be  dealt 
with  as  described  later.  At  this  stage  the  patient  has 
little  discharge,  and  the  early  tenderness  and  irritability 
of  the  whole  lower  urinary  tract  are  wearing  off,  thus 
facilitating  the  examination  and  minimising  the  attend- 
ant discomfort.     The  practice  of  examining  every  case 

23 


24     TREATMENT  OF  GONORRHCEA 

when  first  seen  is  not  good,  for,  besides  occasioning 
anxiety  and  introspection  in  the  patient,  a  wrong  con- 
clusion may  frequently  be  drawn.  Thus,  with  a  recently 
infected  patient  coming  under  observation  early, 
examination  of  the  prostate  may  reveal  nothing,  or 
but  slight  enlargement  and  tenderness,  whereas  a  week 
later  there  are  definite  signs  of  inflammation  and  sup- 
puration. Such  a  case,  being  found  normal  at  first, 
might  be  treated  for  a  considerable  time  before  symp- 
toms or  signs  pointing  to  prostatic  involvement 
would  be  sufficiently  marked  to  lead  to  another 
examination. 

Indications  for  examination.  (Apart  from  the 
routine  examination.) 

Urine. — This  may  give  indications  of  prostatic  trouble 
in  three  ways ; 

(i)  The  presence  of  characteristic  filaments  in  the 
urine. 

(2)  Persistent  cloudiness  of  both  glasses  in  the  2- 
glass  test,  with  an  almost  complete  absence  of  discharge 
from  the  urethra. 

(3)  Rapid  reappearance  of  cloudiness  in  both  test 
glasses  when  all  treatment  has  been  stopped.  (This 
is  frequently,  but  by  no  means  invariably,  due  to  the 
prostate.) 

The  absence  of  the  characteristic  filaments  is  no 
criterion  for  assuming  that  the  prostate  is  normal,  but 
the  positive  observations  mentioned  in  (2)  and  (3)  are 
much  more  reliable. 

Other  indications  are  : 

(1)  Frequency  of  micturition,  usually  worse  at  night 
than  in  the  daytime. 

(2)  Pain  referred  to  the  bladder,  rectum,  or  tip  of  the 
penis, 


EXAMINATION   OF  THE   PROSTATE        25 

(3)  Appearance  of  a  discharge  at  the  meatus  after  the 
bowels  have  acted. 

(4)  Difficulty  in  commencing  the  act  of  micturition, 
or  intense  desire  to  micturate  with  inability  to  pass 
more  than  a  few  drops  of  urine  at  intervals  of  a  few 
minutes,  or  retention. 

(5)  Obstinate  constipation. 

Individually  these  are  not  pathognomonic,  but  when 
several  are  present  the  prostate  will  usually  be  found 
to  be  affected.  These  signs  are  well  marked  in  Acute 
Prostatitis,  as  would  be  expected,  and  most,  if  not  all, 
are  then  present. 

Method  of  Examination. — The  most  satisfactory 
position  for  the  patient  is  kneeling  on  a  moderately  low 
couch  and  resting  on  one  hand,  whilst  the  other  hand 
holds  the  test-glass  beneath  the  penis.  It  is  approxi- 
mately the  "  Knee-elbow  "  position  of  gynaecology.  The 
use  of  a  suppository  containing  atropine  before  the 
examination  is  a  safe-guard  against  the  subsequent  de- 
velopment of  epididymitis,  and,  in  addition  to  diminish- 
ing the  discomfort,  relaxes  the  anal  sphincter. 

Systematic  investigation  of  the  following  points  should 
be  carried  out  : 

(1)  Size  (of  the  organ). 

(2)  Consistence. 

(3)  Tenderness  on  pressure. 

(4)  Secretion  of  the  gland. 

The  size  of  the  organ  varies  in  different  individuals, 
but  with  experience  the  examining  finger  can  readily 
recognize  pathological  enlargement.  It  may  be  uniform, 
confined  to  one  or  other  lobe,  or  several  loculi  may  be 
distinguished. 

The  consistence  of    a  slightly  inflamed  prostate  is 


26  TREATMENT  OF  GONORRHOEA 

firm  and  resistant,  but  as  suppuration  develops  the 
gland  becomes  softer  and  the  finger  readily  sinks  into  it 
on  pressure,  giving  a  tactile  impression  similar  to  that 
obtained  in  "  pitting  "  of  the  tissues  in  the  oedema  of 
renal  disease.  If  abscess  formation  occur,  an  area  of 
the  gland  may  be  found  involving  the  rectum,  into  which 
the  abscess  occasionally  bursts  spontaneously.  Exami- 
nation of  such  a  case  reveals  a  large  swelling  projecting 
backwards  into  the  anterior  rectal  wall,  one  portion  of 
which  feels  exceedingly  thin  and  fragile  and  fluctuates 
on  the  slightest  pressure.  It  may  burst  into  the  rectum 
when  touched,  however  carefully  the  examination  be 
made,  giving  exit  to  a  considerable  quantity  of  pus. 

The  first  examination  often  gives  rise  to  a  feeling  of 
faintness,  especially  if  suppuration  be  present,  and  this 
should  always  be  watched  for,  both  during  and  just  after 
treatment,  since  it  is  not  confined  entirely  to  the  nervous 
patient. 

A  small  amount  of  tenderness  is  usually  present  on 
massage  of  a  normal  prostate,  and  this  increases  rapidly 
as  inflammation  develops  ;  but,  being  a  subjective 
sensation,  its  value  is  minimised. 

The  character  of  the  secretion  is  most  important. 
During  the  examination  a  conical  test-glass,  containing 
a  little  water,  should  be  held  beneath  the  penis,  and  any 
secretion  expressed  allowed  to  fall  into  it.  Normal 
prostatic  secretion  is  opalescent,  and  imparts  this  charac- 
teristic to  the  water  in  the  test-glass,  but  as  inflamma- 
tion develops  its  character  changes.  From  being  opales- 
cent it  becomes  milky  and  increased  in  quantity,  gradu- 
ally, as  the  inflammation  progresses,  getting  thicker,  so 
that  two  layers  can  be  distinguished  in  the  test-glass  on 
standing:  (i)  A  white  layer  of  muco-pus  which  sinks 
to   the  bottom.      (2)  An  opaque  milky  layer  above. 


EXAMINATION   OF   THE   PROSTATE        27 

Later,  abscess  formation  occurs  and  thick  yellow  pus  can 
be  expressed. 

Acute  Prostatitis 

This  complication  is  described  here  because  of  its 
intimate  relationship  to  the  subject  matter  of  the 
chapter  and  the  various  signs  enumerated  as  indications 
of  prostatic  involvement.  For  descriptive  purposes 
three  forms  are  recognizable :  Acute,  Sub-acute,  and 
Chronic;  but  it  must  be  realized  that  clinically  they  merge 
one  into  the  other  without  any  very  definite  lines  of 
demarcation.  Thus,  a  case  of  acute  prostatis  may  under 
suitable  treatment  rapidly  become  sub-acute,  and  then, 
if  treatment  be  neglected  or  stopped  too  early,  reach  the 
chronic  stage. 

It  usually  develops  about  the  seventh  to  twenty- first 
day  of  discharge,  its  onset  being  rapid.  Pain  is  often 
the  first  warning,  dull  and  dragging  in  character,  referred 
to  the  rectum,  the  bladder,  or  the  tip  of  the  penis.  There 
may  be  the  history  of  the  passage  of  a  little  blood  at 
the  end  of  micturition  during  the  preceding  twenty- four 
hours ;  but  this  is  often  absent.  The  pain  increases  in 
intensity  and,  side  by  side  with  this,  difficulty  in  mic- 
turition, with  frequency,  develops,  until,  when  the  acute 
stage  is  at  its  height,  there  may  be  retention.  Distressing 
spasms  of  the  prostate  keep  the  patient  restless,  and  the 
associated  inflammation  at  the  neck  of  the  bladder  leads 
to  repeated  attempts  to  pass  water,  though  it  contains 
but  a  few  drops.  The  temperature  soon  rises,  and  may 
reach  1020  or  1030,  the  patient  is  flushed  and  wears  an 
anxious  expression,  his  attitude  being  very  similar  to 
that  assumed  by  abdominal  cases — lying  on  the  back, 
the  knees  drawn  up  on  the  abdomen,  and  afraid  almost 
to   move.     The   discharge   diminishes   to   a   negligible 


28  TREATMENT   OF   GONORRHCEA 

quantity,  especially  if  the  temperature  be  moderately 
high,  and  there  is  obstinate  constipation,  made  worse 
by  reflex  inhibition  from  the  inflamed  gland  whenever 
there  is  any  pressure  on  the  anterior  rectal  wall.  In  this 
state  a  condition  of  exhaustion  rapidly  develops,  and  the 
patient  can  neither  sit  nor  lie  down  with  any  degree  of 
comfort. 

Diagnosis. — A  patient  seen  at  this  stage  might  well, 
at  first  sight,  be  mistaken  for  an  acute  abdominal  case  ; 
but,  if  already  under  treatment,  the  condition  is  readily 
understood.  A  history  of  urethral  discharge  makes 
diagnosis  simple,  but  this  is  seldom  volunteered  without 
special  inquiry,  and  may  even  be  denied.  The  diag- 
nostic points  are : 

(i)  Urethral  discharge.  A  film  shows  the  gonococcus. 
It  is  rare,  in  such  cases,  for  there  to  be  insufficient  dis- 
charge for  this. 

(2)  Tenderness  is  much  more  marked  on  pressure 
over  the  perineum  than  over  the  lower  abdomen. 

(3)  There  is  frequency  of  micturition,  or  retention. 

(4)  Rectal  examination  reveals  an  enlarged  and 
acutely  tender  prostate.  The  presence  of  epididymitis 
concurrently  may  complicate  matters,  but  even  then 
the  tenderness  is  most  marked  in  the  groin,  and  enlarge- 
ment of  the  testicle  is  obvious. 

Treatment. — A  rectal  examination  should  be  made 
to  discover  the  exact  condition  of  the  gland,  but  massage 
should  not  be  carried  out  at  this  stage.  Having  con- 
firmed the  diagnosis,  treatment  falls  under  three  head- 
ings :  1.  Relief  of  pain.  2.  Relief  of  frequency  or  reten- 
tion.    3.  Sleeping-draughts. 

A  hot  hip-bath  should  be  given  at  once  and  the  patient 
allowed  to  sit  in  it  for  a  quarter  of  an  hour,  hot  water 
being  continually  added  so  as  to  maintain  the  tempera- 


EXAMINATION   OF   THE   PROSTATE        29 

ture  as  high  as  can  be  comfortably  borne.  It  is  in- 
advisable to  continue  this  beyond  a  quarter  of  an  hour, 
for  there  is  a  tendency  for  faintness  to  supervene. 
Following  on  the  bath  a  suppository  containing  y^th  of 
a  grain  of  atropine  should  be  given,  and  hot  fomenta- 
tions or  an  india-rubber  hot  water  bottle  applied  to  the 
perineum.  An  almost  immediate  sense  of  relief  is  felt 
and  the  patient  can  lie  comfortably  in  bed.  The  atro- 
pine suppository  assists  in  diminishing  the  frequency  of 
micturition,  as  well  as  in  relieving  pain,  and  its  action 
should  be  continued  by  giving  the  following  mixture 
everv  four  hours  : 


^. 


Potass.  Citratis. 
Tinct.  Hyoscyami. 
Tinct.  Belladonn. 
Glycerin!.   . 
Syr.  Zingiber. 


grs.   xx. 

m.  xx. 

m.     v. 

m.  xxx. 

m.  xxx. 

Aqua  ad  1  ounce. 


When  administering  this  drug  its  action  on  the  glands 
and  pupil  must  not  be  forgotten,  since  after  two  or  three 
days'  treatment  the  patient  may  complain  of  difficulty 
in  reading  or  seeing  near  objects,  dryness  of  the  mouth, 
and  thirst.  The  pupils  are  found  to  be  dilated,  and  the 
cause  of  the  condition  is  clear. 

If  retention  develops  a  soft  rubber  catheter  (or  gum- 
elastic)  should  be  passed,  with  aseptic  precautions  and 
the  urine  drawn  off.  This  will  need  to  be  repeated 
during  the  acute  stage,  but  after  forty-eight  hours' 
suitable  treatment  the  patient  is  usually  able  to  pass 
water  fairly  freely.  The  pain  and  febrile  condition 
prevent  sleep,  and  this  is  best  secured  by  using  a  bromide 
mixture  towards  evening,  two  doses  of  x.  or  xv.  grains 
being  given  with  an  interval  of  three  or  four  hours  between 


3o  TREATMENT   OF  GONORRHOEA 

them.  It  has  the  additional  advantage  of  a  sedative 
action  on  the  genital  tract  which  is  not  shared  by 
trional  or  aspirin,  though  otherwise  they  are  equally 
good. 

No  irrigation  should  be  allowed  until  the  pain  has 
moderated  considerably  and  the  patient  can  pass  water 
freely.  A  weak  solution  of  permanganate  of  potash 
(i  in  8,000)  should  then  be  given  twice  daily,  the  hip- 
baths and  suppository  being  continued.  The  use  of 
vaccine  is  a  most  valuable  adjunct,  and  will  be  referred 
to  in  another  chapter.  When  the  sub-acute  stage  has 
been  reached  routine  massage  should  be  commenced, 
twice  a  week  being  sufficiently  often  for  the  majority 
of  cases.  In  carrying  this  out  the  gland  should  be 
firmly  and  evenly  stroked  from  above  downwards,  the 
finger  sweeping  over  the  surface  in  small  curves  directed 
toward  the  centre  of  the  gland,  so  as  to  include  the  out- 
lying, as  well  as  the  central  portions.  The  secretion 
expressed  is  collected,  as  previously  described,  in  a  test- 
glass  containing  a  little  water.  Regular  massage  should 
be  continued  until  pus  does  not  re-form  and  normal 
secretion  alone  is  expressed.  Hip-baths  should  still 
be  given,  and  the  irrigations  twice  daily,  the  strength 
of  the  solution  being  increased  to  1  in  6,000. 

Some  of  the  cases  do  not  clear  up,  but  pass  into  the 
chronic  stage,  and  for  weeks  or  months  pus  or  muco- 
pus  can  be  expressed  from  the  prostate,  with,  perhaps, 
a  little  blood.  The  administration  of  a  gonococcal 
vaccine  has  been  found  very  effective  in  such,  and  should 
always  be  tried  along  with  routine  treatment.  In  others 
the  openings  of  the  prostatic  ducts  into  the  posterior 
urethra  may  be  enlarged  through  the  urethroscope,  but 
this  needs  special  instruments  and  technique  and  should 
be  left  to  the  specialist. 


EXAMINATION   OF  THE   PROSTATE        31 

Chronic  Prostatitis 

In  a  very  large  number  of  gonorrhoea  cases  the  infec- 
tion spreads  to  the  prostate,  and  some  writers  put  the 
figure  as  high  as  80  per  cent.  ;  but  it  must  be  explained 
that  symptoms  of  acute  prostatitis  such  as  have  just 
been  described  develop  only  in  a  very  much  smaller 
number,  and  even  this  number  can  be  reduced  by  the 
proper  use  of  vaccines  in  the  early  acute  stage.  In  some 
cases  many  of  the  signs  already  enumerated  are  obvious, 
such  as  frequency  of  micturition,  characteristic  filaments 
in  the  urine,  the  appearance  of  a  discharge  at  the  meatus 
after  an  action  of  the  bowels,  or  dragging  pain  when 
walking  about.  Many  show  no  signs  at  all  of  the  exten- 
sion of  infection  to  the  prostate,  and  it  is  only  during 
routine  examination  that  the  condition  of  the  gland  is 
discovered.  The  two-glass  urine  test  is  often  quite 
valueless  as  a  guide  in  these  cases,  for  the  second  glass 
may  be  perfectly  clear  and  free  from  filaments  when  pus 
or  muco-pus  can  be  expressed  from  the  prostate  on 
massage.  This  fact  is  responsible  for  many  relapses, 
since  examination  of  the  gland  is  often  neglected.  The 
patient  stops  treatment  and  goes  about  as  usual  with 
no  discharge,  and  then,  as  the  result  possibly  of  a  chill, 
over-exertion,  or  even  constipation,  there  is  a  discharge 
from  the  prostate,  the  urethra  becomes  re-infected,  and 
a  relapse  results.  Such  relapses  can  be  avoided,  in  many 
instances,  by  proper  treatment  of  the  prostate,  and  in 
every  case  of  gonorrhoea  it  should  be  the  aim  of  the 
surgeon  to  ensure  that  normal  secretion  only  is  present 
in  the  gland  when  treatment  is  to  be  discontinued.  The 
method  of  examination  has  been  described  previously, 
together  with  the  characters  of  normal  secretion.  The 
point  of  chief  importance  in  chronic  prostatitis  is  the 


32  TREATMENT  OF  GONORRHOEA 

nature  of  the  secretion  expressed.  The  gland  is  usually 
found  to  be  moderately  enlarged,  and  but  slightly  tender, 
whilst  the  seminal  vesicles  may  be  involved  as  well. 
There  is  slight  discomfort  on  massage,  but  nothing 
approaching  the  severe  pain  of  the  acute  stage.  The 
consistence  of  the  gland  varies  considerably,  in  many 
patients  being  firm  and  resistant,  very  much  like  the 
normal,  but  in  a  certain  number  fibrosis  occurs  leading 
to  a  hard  and,  often,  nodular  condition.  During  massage 
of  these  latter  cases  it  requires  considerable  pressure  to 
express  any  secretion,  and  it  may  be  that  there  is  an 
associated  constriction  or  occlusion  of  some  of  the 
ducts. 

Treatment. — It  takes  a  considerable  time  thoroughly  to 
clear  up  some  of  these  cases  of  chronic  prostatitis  and, 
owing  to  this  fact,  there  is  a  tendency  for  the  patient 
to  become  despondent  and  worried  about  himself.  The 
nature  of  the  treatment  encourages  introspection,  and, 
if  care  be  not  taken,  an  unhealthy  state  of  mind  is  soon 
developed.  For  this  reason  attention  should  be  paid  to 
the  general  health  and  mode  of  living.  Tonics  are 
prescribed  if  needed,  food  restriction  and  dieting  done 
away  with  as  far  as  possible,  and  the  patient  encouraged 
to  take  plenty  of  exercise  in  the  open  air,  avoiding  riding 
and  cycling.  In  one  series  of  cases  treated  with  vac- 
cines it  was  found  that  the  cases  complicated  by  pros- 
tatitis (including  acute  as  well  as  chronic)  took,  on 
an  average,  three  weeks  longer  than  those  with  epidi- 
dymitis.    The  actual  figures  were  : 

Epididymitis  :    101  cases.     Average  number  of  days, 

38. 

Prostatitis  :   94  cases.     Average  number  of  days,  60. 
No  doubt  the  period  of  treatment  for  these  cases 
might  have  been  shortened  by  a  few  days  at  the  risk 


EXAMINATION   OF  THE  PROSTATE        33 

of  relapses  occurring,  but  it  is  more  satisfactory  to  treat 
the  condition  thoroughly.  In  the  cases  quoted  no 
relapses  had  occurred  at  a  period  six  months  after 
completion  of  treatment.  The  lines  of  treatment  are 
four  : 

(a)  Baths,  combined  with  irrigation. 

(b)  Regular  massage  of  the  prostate. 

(c)  Vaccine  treatment. 

(d)  Instrumental  treatment.     (Bougies   and  di- 

lators). 

Medicinal  treatment  has  little  or  no  effect  upon  the 
prostate,  as  far  as  is  known,  and  there  is  no  particular 
drug  of  value.  Sandal-wood  oil  or  a  mixture  of  uro- 
tropine  and  buchu  is  suitable. 

Hip-baths  are  very  useful  in  the  chronic,  as  well  as  in 
the  acute,  stage.  The  patient  should  take  the  bath 
daily,  as  hot  as  can  be  comfortably  borne,  the  tem- 
perature being  maintained  by  the  addition  of  hot  water, 
as  already  described  for  acute  prostatitis.  Irrigation 
of  the  whole  urethra  should  be  carried  out  daily,  after  the 
bath,  in  order  to  wash  away  any  secretion  exuding 
from  the  prostate.  Zinc  permanganate  is  a  very  useful 
solution  for  this  purpose,  and  may  be  used  in  a  strength 
of  1  in  4,000. 

Massage  of  the  prostate  should  be  carried  out  regularly 
in  the  manner  already  described,  a  suppository  con- 
taining atropine  being  given  on  the  evening  before  the 
examination  and  again  one  hour  before  it  is  actually 
carried  out.  This  diminishes  the  likelihood  of  Epidi- 
dymitis resulting,  but  with  all  precautions  its  occurrence 
cannot  always  be  prevented.  Special  attention  should 
be  paid  to  each  part  of  the  gland,  and  care  taken  not 
to  overlook  a  focus  in  the  lateral  areas.     In  the  chronic 

3 


34  TREATMENT  OF  GONORRHOEA 

stage  there  is,  frequently,  loculation  and,  consequently, 
should  the  examination  lack  thoroughness,  an  infected 
area  may  remain  untouched  after  repeated  massage, 
and  nothing  but  normal  secretion  be  expressed  each 
time,  a  fact  which  would  be  liable  to  mislead. 

In  certain  cases  the  prostate  is  found  to  be  hard  and 
its  contents  difficult  to  express.  Under  these  condi- 
tions it  sometimes  improves  matters  to  carry  out  the 
massage  with  a  curved  metal  sound  in  position  in  the 
posterior  urethra.  This  diminishes  the  mobility  of  the 
gland  and  allows  its  different  areas  to  be  compressed 
against  the  metal  shaft.  The  frequency  with  which 
this  examination  needs  to  be  carried  out  is  determined 
by  the  condition  of  the  gland  and  the  character  of  the 
secretion,  but  should  never  be  more  than  twice  a  week. 
If  there  be  only  a  small  amount  of  pus  or  muco-pus 
expressed  at  each  massage  the  interval  can  be  extended 
to  a  week,  and  this  is  the  common  rule. 

Instrumental  treatment  is  required  in  some  obstinate 
cases  where  massage  and  irrigation  do  not  suffice  to  clear 
up  the  condition.  Urethroscopy  has  shown  that  in 
many  of  these  there  is  a  focus  of  infection  in  the  posterior 
urethra,  often  in  the  region  of  the  prostatic  sinus, 
responsible  for  keeping  up  the  discharge.  The  best 
instruments  for  this  purpose  are  large  curved  bougies 
with  a  short  beak,  the  pattern  known  as  Clutton's 
being,  perhaps,  the  best.  After  thorough  irrigation  of 
the  urethra  and  bladder  an  injection  of  2  per  cent, 
alypin  is  given  into  the  posterior  urethra,  by  means  of 
an  Ultzmann's  syringe,  and  the  sound  passed  with  full 
aseptic  precautions.  Two  instruments,  or  possibly  three, 
may  be  passed  at  each  visit,  but  never  more. 

They  need  not  be  left  in  position,  being  simply  in- 
serted and  withdrawn  gently.     Irrigation  is  then  carried 


EXAMINATION   OF   THE   PROSTATE        35 

out  once  more.     An  interval  of  a  week  should  be  allowed 
to  elapse  between  each  treatment. 

Kollmann's  posterior  urethral  dilator  may  be  used  in 
certain  cases,  e.g.  when  the  instruments  of  Glutton's 
pattern  have  not  been  sufficient  to  produce  the  necessary 
dilatation  of  the  posterior  urethra,  as  shown  by  the 
urethroscope.  It  is  an  instrument  which  is  but  seldom 
required,  and  should  be  used  only  for  a  definite  purpose, 
and  always  controlled  by  urethroscopic  examination. 
The  instrument  is  of  the  four-bladed  type,  the  irrigating 
pattern  being  preferable,  so  that  a  solution  of  protargol 
or  silver  nitrate  may  be  run  through  during  dilatation. 
Suitable  strengths  for  this  purpose  are  1  in  4,000  pro- 
targol and  1  in  10,000  to  1  in  5,000  silver  nitrate.  The 
introduction  and  subsequent  expansion  of  the  blades 
should  be  carried  out  with  the  greatest  care,  since  the 
posterior  urethra  is  not  nearly  so  elastic  and  distensible 
as  the  anterior  portion.  The  method  is  similar  in  all 
essential  details  to  that  previously  described  for  Koll- 
mann's straight  dilator,  and  need  not  be  repeated  here. 
An  interval  of  a  week  should  always  be  allowed  between 
these  dilatations  and  the  effect  of  each  preceding  one 
estimated  by  means  of  the  urethroscope  before  repeating 
the  operation.  By  this  means  satisfactory  results  can 
be  obtained  and  the  risk  of  serious  damage  minimised. 

Vaccines  are  of  the  greatest  value  in  cases  of  chronic 
prostatitis,  especially  where  pus  or  muco-pus  continues 
to  re-form  rapidly  in  spite  of  repeated  massage.  In 
many  such  cases  the  only  sign  is  the  appearance  of  a 
little  white  secretion  at  the  meatus  after  an  action  of 
the  bowels,  while  the  urine  in  both  glasses  of  a  two-glass 
test  is  perfectly  clear.  Such  patients  get  very  worried 
over  this  morning  discharge,  even  when  gonococci  can- 
not be  found  in  a  smear  from  it,  and  it  is  essential  to  clear 


36  TREATMENT   OF   GONORRHCEA 

it  up  as  rapidly  as  possible.  The  prostate  gets  into  a 
catarrhal  condition,  and  massage  alone  does  not  seem  to 
have  much  influence  ;  but  when  combined  with  vaccines 
a  steady  improvement  can  be  observed.  A  dose  of 
ioo  million  gonococci  and  300  million  staphylococci 
should  be  given  twice  weekly,  and  massage  carried  out 
once  a  week,  followed  by  an  irrigation  of  iin  6,000  perman- 
ganate of  potash.  If  the  urine  be  clear  and  contain  no 
filaments,  irrigation  is  unnecessary,  except  directly  after 
the  massage.  One  case  may  be  quoted  as  an  example. 
The  patient  had  an  attack  of  gonorrhoea,  with  acute 
inflammation  of  the  prostate.  This  subsided  after  six 
weeks'  treatment,  and  the  urine  was  perfectly  clear.  The 
prostate,  however,  remained  somewhat  enlarged  and 
continued  in  a  catarrhal  condition.  Much  muco-pus 
could  always  be  expressed  on  massage,  though  no  dis- 
charge was  ever  seen  except  after  an  action  of  the  bowels, 
and  there  was  no  discomfort.  The  patient  was  sent 
away  for  a  month  and  a  complete  rest  from  all  treatment 
allowed.  At  the  end  of  that  time  a  smear  of  the  prostatic 
secretion  was  examined.  Gonococci  were  found  to  be 
present.  A  course  was  commenced  on  the  lines  already 
described,  with  vaccine  at  regular  intervals  and  weekly 
massage  of  the  prostate,  no  irrigation  being  allowed 
except  once  after  each  examination.  At  the  end  of  six 
weeks  the  prostate  was  of  normal  size  and  consistence, 
its  secretion  having  gradually  changed  from  muco-pus 
to  the  characteristic  opalescent  fluid.  A  second  smear 
was  then  taken.  No  gonococci  could  be  found.  All 
treatment  was  stopped,  and  the  patient  seen  again  three 
months  later.  The  prostate  remained  normal,  as  also 
its  secretion,  and  no  gonococci  could  be  found  after 
examination  of  two  slides  taken  at  a  few  days'  interval. 
No  sign  of  discharge  had  been  present  at  any  time  and 


EXAMINATION  OF  THE   PROSTATE        37 

the  cure  was  complete.  An  experience  of  many  similar 
cases  treated  by  other  methods  has  led  the  writer  to 
attribute  a  definite  action  to  the  vaccine  which  is 
extremely  valuable,  and  is,  fortunately,  most  useful  in 
those  cases  which  would  otherwise  require  very  pro- 
tracted treatment,  although  the  manifestations  are  so 
aggravatingly  slight. 


CHAPTER  V 

ROUTINE  TREATMENT  OF  ACUTE  GONORRHOEA 

During  the  acute  stage  of  the  disease  rest  in  bed  and 
a  light  diet  are  the  first  essentials.  Apart  from  any 
treatment  this  results  in  a  speedy  diminution  of  the  dis- 
charge, and  it  is  a  safe  plan  to  keep  a  patient  in  bed  until 
there  is  little  more  than  a  yellow  bead  of  pus  visible 
at  the  meatus  in  the  morning.  If  the  system  of  early 
vaccine  treatment,  as  described  later,  be  adopted,  this 
usually  happens  after  four  or  five  days.  Other  treatment 
can  be  conveniently  described  under  three  headings: 

(i)  General. 

(2)  Local. 

(3)  Special. 

General  treatment  includes  medicines — (a)  urinary 
antiseptics ;  (b)  aperients ;  (c)  sedatives  ;  together 
with  the  nature  of  the  diet. 

Local  treatment  includes  irrigations  and  instrumental 
procedure. 

Special  treatment  includes  vaccines,  mercury  com- 
pounds, electro- chemical  methods. 

Diet. — -This  should  be  light  in  the  acute  stage,  as 
already  mentioned,  and  include  plenty  of  fluid.  Milk 
and  barley-water  are  both  suitable,  and  two  to  four  pints 
of  the  latter  should  be  taken  daily.  It  is  a  perfectly 
bland  fluid,  and,  with  the  addition  of  lemon,  makes  quite 

38 


ROUTINE  TREATMENT  39 

a  palatable  drink.  A  little  tea  or  coffee  may  be  allowed, 
but  no  alcohol  of  any  description.  This  regime  con- 
tinues until  the  fourth  or  fifth  day,  when  the  patient 
gets  up  and  may  be  permitted  an  ordinary  diet.  Spices, 
highly  seasoned  foods,  sauces,  and  pickles  should  be 
avoided  and  alcohol  still  forbidden ;  but  a  moderate 
amount  of  meat  may  safely  be  taken. 

Exercise. — On  being  allowed  up  the  patient  should 
begin  to  take  exercise  each  day,  the  amount  being 
gradually  increased  as  the  acute  stage  passes  off.  There 
is  a  mistaken  idea  amongst  many  sufferers  from  the  disease 
that  it  is  a  wise  practice  to  abstain  from  meat  and  take 
no  exercise  for  some  weeks  after  its  development  ;  but 
experience  shows  this  to  be  wrong.  By  the  tenth  day 
an  uncomplicated  case  of  gonorrhoea  should  be  eating 
a  full  diet,  with  the  exceptions  mentioned,  going  about 
as  usual,  and,  in  fact,  leading  an  ordinary  life.  By 
following  this  course,  too,  the  mind  is  turned  away  from 
the  disease,  and  it  ceases  to  be  the  nightmare  which  it 
frequently  becomes  on  prolonged  semi-starvation  and 
confinement  to  bed. 

Medicines. — Urotropine  is  a  useful  drug  in  the  acute 
stage,  being  a  urinary  antiseptic.  It  should  be  given 
with  acid  sodium  phosph.,  mixed  just  before  taking, 
so  as  to  secure  its  full  effect.  A  useful  prescription  is 
the  following : 


Urotropine 
Aq.  ad. 
B.     Ac.  Sod.  Phosph. 
Potass.  Citrat.    . 
Syr.  Aurant. 
Inf.  Buchu  ad  1  ounce  t.d.s. 


grs.  x. 
1  ounce 
grs.  xx. 
grs.  x. 
3is. 


Dose. — 1  ounce  of  each  "mixed  just  before  taking. 


40     TREATMENT  OF  GONORRHOEA 

Some  patients  are  intolerant  of  this  drug,  and  com- 
plain of  an  increased  irritability  of  the  bladder  and 
urethra,  with  considerable  frequency,  quite  apart  from 
any  prostatic  complication.  It  should  not  be  given 
when  there  is  acute  posterior  urethritis,  with  bleeding 
at  the  end  of  micturition.  Sandal- wood  oil  and 
copaiba  seem  to  have  little  effect  on  the  course  of  the 
disease  at  this  stage.  Aperients  are  usually  required 
to  keep  the  bowels  acting  regularly,  and  this  point  should 
always  receive  attention.  Magnesium  salts  are  the  most 
suitable  for  the  purpose,  and  the  dose  can  be  readily 
regulated  by  the  patient  to  suit  his  own  needs. 

Sedatives  are  called  for  in  the  case  of  the  painful 
erections  which  are  a  common  symptom.  Potassium 
bromide  in  grs.  x.  doses,  given  towards  evening  and 
again  on  retiring,  is  quite  effective. 

Local  Treatment. — Irrigation  should  be  commenced 
as  soon  as  the  condition  has  been  diagnosed,  and  every 
attempt  made  to  get  the  irrigating  fluid  into  the  bladder 
at  the  earliest  possible  moment. 

Two  conditions  alone  contra-indicate  this  : 

(i)  The  presence  of  an  acute  epididymitis. 

(ii)  A  hyper-acute  urethritis,  such  as  is  occasionally 
seen,  in  which  blood  and  pus  ooze  constantly  from  the 
urethra. 

In  these  cases  other  measures  have  to  be  adopted 
for  a  time  before  irrigation  can  be  commenced,  but  in  all 
others  no  delay  should  take  place  in  washing  out  the 
whole  urethra. 

The  most  generally  useful  solution  is  i  in  8,000  per- 
manganate of  potash,  and  two  or  three  pints  should  be 
used  for  each  irrigation,  the  temperature  being  between 
ioo°  and  1050  F.  in  the  can.  If  colder  than  this  it  does 
not  enter  the  bladder  so  readily. 


ROUTINE  TREATMENT  41 

The  apparatus  consists  of  a  can  of  two  or  three  pints 
capacity,  to  which  is  connected  a  piece  of  rubber  tubing 
about  4  feet  in  length.  A  blunt-ended  glass  nozzle  is 
attached  to  the  free  end  of  the  tubing,  and  the  flow  of 
fluid  controlled  by  a  ratchet-clip.  The  can  is  filled  with 
the  permanganate  solution  (1  in  8,000)  at  the  proper 
temperature  and  suspended  about  6  to  7  feet  above  the 
ground.  The  patient  wears  a  waterproof  apron  and 
either  sits  or  stands  with  a  bucket  at  his  feet  to  catch 
the  waste  fluid.  The  clip  is  released  and  all  air  expelled 
from  the  tubing,  the  flow  of  fluid  being  controlled 
by  the  pressure  of  the  fingers.  The  prepuce  is  re- 
tracted and  the  meatus  washed  free  from  any  accu- 
mulated discharge  by  a  gentle  flow  of  the  solution.  The 
nozzle  is  then  pressed  firmly  against  the  meatus  and  the 
fluid  allowed  to  run  freely.  It  can  be  felt  to  run  up  a 
short  wa3?  and  then  stop.  The  nozzle  is  then  withdrawn 
and  a  jet  of  the  solution  runs  away.  This  is  repeated 
four  or  five  times  and  the  nozzle  reapplied  more  firmly, 
so  that  nothing  escapes  at  the  meatus.  The  muscles  are 
relaxed  in  exactly  the  same  way  as  during  micturition 
and  the  fluid  allowed  to  run  freely.  The  bladder  can  then 
be  felt  to  fill  up  gradually,  and  a  desire  to  pass  water 
supervenes.  The  clip  is  closed,  the  nozzle  withdrawn, 
and  the  patient  empties  his  bladder.  This,  too,  should 
be  repeated  two  or  three  times.  Some  patients  find  a 
difficulty  in  relaxing  the  muscles  to  allow  free  passage 
to  the  fluid,  but  in  these  a  change  from  the  standing 
to  the  sitting  position  during  irrigation  will  often  over- 
come the  difficulty,  or  vice  versa.  A  certain  proportion 
of  cases  have  some  malformation  of  the  penis,  such  as 
hypospadias  of  various  degrees.  For  these  a  special 
nozzle  with  a  long  thin  neck  to  insert  well  inside  the 
meatus  is  necessary. 


42     TREATMENT  OF  GONORRHOEA 

Irrigation. — This  should  be  done  twice  a  day,  in  the 
morning  and  again  towards  evening,  the  whole  content 
of  the  can  being  utilised  each  time.     After  a  few  days 
the  discharge  diminishes  considerably,  and  as  soon  as 
the  patient  can  irrigate  successfully  the  strength  should 
be  increased  to  i  in  6,000  permanganate,  beyond  which 
it  is  not  necessary  to  go  in  the  ordinary  acute  case. 
Such   a   solution   has   comparatively   little   germicidal 
effect  during  its  short  stay  in  the  urethra,  and  the  object 
of  irrigation  is,  almost  entirely,  that  of  flushing  out  the 
inflamed  lower  urinary  tract ;   consequently  the  volume 
of  solution,  not  the  strength,  is  of  first  importance. 
Patients  are  very  apt  to  imagine  that,  by  using  a  very 
strong  solution  which  causes  them  more  discomfort, 
they  are  benefiting  themselves  and   cutting  short  the 
duration  of  the  attack.    This  is  a  fallacy,  and,  although 
a  certain  number  of  cases  require  a  stronger  solution, 
it  is  unusual,  and  1  in  6,000  permanganate  is  sufficient 
for    the    vast    majority.     Since   irrigation    has    to   be 
continued  for  three  or  four  weeks  in  the  most  favourable 
cases  it  is  sound  reasoning  that  the  solution  which  does 
least  damage  to  the  epithelium  is  the  best.     Irrigation 
with  1  in  4,000  permanganate  for  two  or  three  days  de- 
termines, in  many  instances,  the  onset  of  slight  bleeding 
at  the  end  of  micturition,  arising  from  injury  to  the 
delicate  mucous  membrane  of  the  posterior  urethra. 
This  rarely  occurs  with  1  in  6,000  permanganate  which 
is  the  most  suitable  strength  for  regular  daily  use  in  the 
acute  stage.     Many  other  solutions  have  been  advocated 
as   superior   substitutes   for   permanganate   of   potash, 
chiefly  for  use  in  the  chronic  stage,  most  of  them  being- 
compounds  of  zinc  or  mercury,  e.g.  zinc  permanganate, 
zinc   sulphate,   mercury   oxycyanide,    zinc    sulphocar- 
bolate.     Experience  shows  that  potass,  permanganate 


ROUTINE  TREATMENT  43 

is  by  far  the  best  in  the  acute  stage,  and  although  no 
specific  action  can  be  definitely  asserted,  its  effects  are 
not  approached  by  any  of  the  other  solutions.  The  merits 
of  each  are  referred  to  under  the  treatment  of  chronic 
gonorrhoea.  Zinc  permanganate  and  zinc  sulphate  are 
often  of  value  towards  the  end  of  treatment  in  an  acute 
case  when  the  urine  is  practically  clear  and  there  is 
an  almost  complete  absence  of  discharge,  or  just  a  little 
adhesion  of  the  lips  of  the  meatus  in  the  morning ;  1  in 
6,000  zinc  permg.  and  1  in  1,000  zinc  sulphate  are  suitable 
strengths,  and  the  change  seems  to  have  a  stimulating 
effect  on  the  urethral  mucosa,  possibly  due  to  the 
astringent  nature  of  the  solution,  resulting  in  the  speedy 
disappearance  of  all  signs  of  dampness  and  of  the  small 
flakes  from  the  urine. 

Bougies. — A  straight  pattern  bougie  should  be  passed 
about  the  end  of  the  second  week  of  treatment,  not  for 
the  purpose  of  dilatation  but  as  a  means  of  investigating 
the  condition  of  Littre's  glands  and  discovering  the  com- 
mencement of  soft  strictures.  A  sound  of  a  size  which 
passes  readily  is  introduced,  and  gentle  traction  in  an 
upward  direction  made  on  the  penis  with  one  hand  whilst 
the  thumb  and  index-finger  of  the  other  hand  palpate  the 
urethra  from  the  bulb  towards  the  meatus.  Small  glan- 
dular abscesses  are  in  this  way  readily  discovered  and 
massaged  against  the  sound  to  express  their  contents. 
Dilatation  should  not  be  attempted  at  this  stage,  but  the 
number  of  the  sound  used  should  be  recorded  for  future 
reference. 


CHAPTER   VI 

SPECIAL   TREATMENT 

Foremost  amongst  these  is  vaccine  as  an  aid,  not  only 
in  preventing  complications,  but  in  materially  assisting 
a  cure.  An  experience  of  some  thousands  of  cases*  treated 
from  the  earliest  stages  on  this  plan  has  confirmed  the 
view  that  vaccines  are  equally  of  value  in  the  acute,  as 
well  as  in  the  chronic,  stage.  A  mixed  stock  vaccine 
gives  the  most  satisfactory  results,  and  in  the  method  to 
be  described  later  one  of  the  following  composition  was 
adopted : 

Staphylococci         .  .     150  millions  per  c.c. 

Gonococci  50  „  „ 

The  cultures  were  made  from  many  different  cases 
and  the  resulting  strains  introduced.  In  treating  gonor- 
rhoea the  difficulty  always  encountered  is  that  of  de- 
stroying in  situ  or  removing  the  gonococci  lying  below 
the  surface  of  the  mucous  lining  of  the  urethra  and  its 
many  tiny  glands.  At  a  very  early  stage  in  the  disease 
the  organisms  penetrate  between  the  cells  and  also  enter 
the  gland  ducts,  and  this  condition  is  almost  invariably 
established  forty-eight  hours  after  the  appearance  of  a 
discharge.  Once  this  has  occurred  it  is  quite  clear  that 
irrigation  alone  will  not  cure  the  patient,  for  the  effect 
is  merely  that  of  washing  away  the  accumulation  of 
*  Vide  British  Medical  Journal,  Oct.  6,  191 7 
44 


SPECIAL  TREATMENT  45 

pus  and  removing  organisms  lying  on  the  surface.  What- 
ever the  nature  or  strength  of  the  solution  it  cannot 
touch  those  organisms  embedded  deep  down  in  the 
various  glands,  and  the  only  satisfactory  way  of  attacking 
them  is  via  the  blood-stream.  A  vaccine  is  the  most 
suitable  medium  for  this  purpose,  since  it  acts  by  increas- 
ing the  power  of  the  blood  to  destroy  the  particular  class 
of  organism  injected.  Following  on  an  injection  there  is 
a  negative  phase,  lasting  from  twenty-four  to  forty-eight 
hours  according  to  the  dose  and  toxicity  of  the  vaccine 
employed,  during  which  the  power  of  the  blood  seems  to 
be  diminished,  followed  by  a  rise  in  its  hostility  to  the 
organisms,  known  as  the  positive  phase,  lasting  longer 
than  the  negative  phase.  It  is  well  known  that  in  the 
case  of  certain  organisms  one  positive  phase  can  be 
superimposed  upon  another  by  giving  injections  at 
suitable  intervals  and  regulating  the  dose  carefully.  The 
gonococcus  is  one  of  these,  and  in  the  method  of  vaccine 
administration  described  below  it  is  believed  that  this 
is  actually  the  case. 

The  dosage  and  intervals  vary  slightly  according  to 
the  vaccine  in  use  and  the  particular  cultures  from  which 
it  is  made,  but  this  can  readily  be  determined  by  experi- 
ment. That  theory  is  borne  out  by  practice  and  that 
the  gonococci  lying  below  the  surface  are  attacked  by 
injecting  vaccine  is  readily  shown.  Take  an  acute  case 
after  two  or  three  weeks'  treatment,  when  the  urine  is 
clear  and  free  from  filaments,  though  the  treatment  is 
not  complete.  Inject  a  dose  of  vaccine  and  examine 
the  urine  twenty-four  hours  later.  It  will  probably  be 
found  cloudy  and  the  patient  may  possibly  see  a  slight 
amount  of  discharge.  This  is  a  very  useful  test  of  cure, 
and  a  moderate  dose  should  be  given  three  or  four  days 
after  all  treatment  has  ceased,  when,  if  there  be  no  return 


46     TREATMENT  OF  GONORRHOEA 

of  discharge  and  the  urine  remain  clear  forty-eight  hours 
later,  there  is  little  likelihood  of  a  relapse.  Vaccine, 
then,  in  the  acute  stage  serves  three  useful  purposes  : 

(i)  To  increase  the  power  of  the  blood  in  antagonising 
the  gonococcus  and  so  incidentally  to  diminish  the 
possibility  of  complications. 

(ii)  To  assist  cure  by  reaching  the  organisms  lying 
beneath  the  mucous  membrane  and  causing  their  de- 
struction or  migration  to  the  surface. 

(iii)  As  a  test  of  cure  on  the  completion  of  treatment. 

The  routine  method  adopted  will  be  fully  described, 
and  all  details  of  diet  and  medicinal  treatment  included, 
since  it  is  the  most  satisfactory  method  of  treatment  at 
present  known. 

When  first  seen  the  patient  is  examined  as  already 
described,  and  the  diagnosis  confirmed.  In  the  morning 
he  passes  a  sample  of  urine,  which  has  been  held  for  six 
or  eight  hours  if  possible,  into  two  conical  test-glasses, 
the  first  four  or  five  ounces  into  the  first  glass,  and  the 
last  few  ounces  into  the  second  glass.  In  the  acute  stage 
both  are  usually  cloudy  if  there  has  been  a  discharge  for 
two  or  three  days.  The  patient  remains  in  bed  and  is 
given  a  mixture  of  urotropine  (prescription  previously 
given)  three  times  a  day,  being  allowed  plenty  of  milk 
and  barley-water.  Irrigation  is  commenced  at  once 
with  i  in  8,000  permanganate  of  potash  twice  a  da}/  and 
every  effort  made  to  ensure  its  entry  into  the  bladder. 
Two  or  three  pints  of  solution  are  used  at  a  temperature 
of  about  ioo°  F.  in  the  irrigating-can,  the  pressure 
being  roughly  four  feet.  An  initial  dose  of  vaccine 
is  given  (i  c.c,  containing  50,000,000  gonococci  and 
150,000,000  staphylococci)  on  the  first  day.  The  patient 
stays  in  bed  four  days  and  continues  the  irrigation 
medicine  and  milk  diet  during  this  period.     On  the  third 


SPECIAL  TREATMENT  47 

day  a  dose  of  2  c.c.  (100,000,000  gonococci,  300,000,000 
staph.)  is  given.  The  strength  of  the  irrigation  is 
increased  to  1  in  6,000  permanganate  on  the  fifth  day, 
when  the  patient  is  allowed  up,  commences  ordinary  diet, 
and  takes  gentle  exercise.  All  alcohol  and  highly-seasoned 
foods  are  forbidden,  but  meat  and  tea  are  allowed.  The 
discharge  at  this  stage  has  almost  invariably  diminished 
to  a  bead  of  pus  in  the  morning  and  micturition  gives 
rise  to  little  discomfort.  On  the  sixth  day  another  dose 
of  2  c.c.  vaccine  is  given  and  irrigation  is  continued  with 
the  same  solution.  On  the  ninth  day  the  vaccine  is 
repeated  (2  c.c.)  and  the  patient  goes  about  just  as  usual, 
taking  no  medicine  and  carrying  out  no  treatment  except 
irrigation  morning  and  afternoon.  Towards  the  end  of 
the  second  week  of  treatment,  when  the  discharge  is  but 
slight,  a  straight  bougie  (metal)  is  passed,  and  the  urethra 
gently  palpated.  If  any  of  the  glands  are  found  enlarged 
they  are  massaged  against  the  sound  from  below  upwards 
between  the  thumb  and  index-finger  so  as  to  express  their 
contents  as  far  as  possible.  Should  any  constriction  of 
the  lumen  have  commenced  to  develop  the  bougie  reveals 
it  and  its  distance  from  the  meatus  is  recorded,  but  no 
attempt  should  be  made  to  dilate  the  urethra  at  this 
stage.  On  the  twelfth  day  another  dose  of  2  c.c.  of 
vaccine  is  given,  the  irrigating  solution  remaining  un- 
altered, and  again  on  the  fifteenth  day.  It  will  be  seen 
that  a  course  of  six  injections  is  thus  given  :  1  c.c.  on  the 
first  day,  2  c.c.  on  the  third,  sixth,  ninth,  twelfth,  and 
fifteenth  days,  the  dose  not  being  increased  after  the  first 
injection. 

General  reaction  has  been  found  to  be  almost  negligible 
after  the  initial  dose  and  subsequent  injections  rarely 
cause  any  headache  ;  but  there  is  always  a  definite  focal 
reaction.     Within  twenty- four  hours  of  the  injection  the 


48  TREATMENT   OF  GONORRHOEA 

discharge  from  the  urethra  increases  slightly  and  pre- 
viously clear  urine  will  probably  be  hazy  on  the  following 
morning  when  the  gonococcus  is  still  active.  About  the 
fifteenth  or  sixteenth  day  a  routine  examination  of  the 
prostate  is  made,  and  the  secretion  examined.  If  an 
acute  case  in  which  treatment  has  been  commenced  early, 
the  normal  secretion  is  usually  present,  but  if  treatment 
has  been  delayed  or  neglected  pus  or  muco-pus  will 
usually  be  found.  Assuming  the  prostate  to  be  normal, 
by  the  sixteenth  to  twentieth  day  all  discharge  will  have 
disappeared,  and  there  will  be  no  bead  in  the  morning, 
nor  after  ordinary  exercise,  whilst  a  two-glass  urine-test 
will  show  both  glasses  clear  with,  perhaps,  a  little  mucus 
and  one  or  two  tiny  flakes  in  the  first.  At  this  stage  the 
irrigation  should  be  changed  to  i  in  1,000  zinc  sulphate 
or  i  in  6,000  zinc  permanganate  for  two  or  three  days, 
and  then  stopped  completely.  Exercise  continues  daily 
as  usual,  and  about  three  days  after  all  treatment  has 
ceased  a  final  dose  of  2  c.c.  vaccine  is  given,  the  urine 
being  examined  on  the  following  morning.  There  should 
be  no  trace  of  discharge,  and  the  urine  should  remain 
perfectly  clear.  The  patient  is  seen  again  after  another 
three  or  four  days,  when,  if  the  samples  are  still  satis- 
factory, there  is  little  likelihood  of  a  relapse. 

In  many  cases  coming  for  treatment,  however,  a  dis- 
charge has  been  present  for  several  days  or  weeks  and  on 
massaging  the  prostate  in  the  routine  course  pus  or 
muco-pus  is  expressed.  If  irrigation  be  discontinued  in 
these  cases  on  the  twentieth  day  and  a  vaccine  given,  a 
copious  discharge  of  pus  results  within  twelve  to  twenty- 
four  hours,  often  described  by  the  patient  as  worse  than 
when  treatment  was  commenced.  Irrigation  must  be 
continued  with  1  in  6,000  permanganate  of  potash  and 
routine  massage  of  the  prostate  started,  but  not  more 


SPECIAL  TREATMENT  49 

often  than  twice  a  week,  unless  there  are  special  indications. 
An  irrigation  should  be  carefully  carried  out  after  each 
massage  so  as  to  remove  any  pus  expressed  into  the 
posterior  urethra. 

Note. — The  tendency  of  some  patients  to  faint  during 
this  treatment  has  already  been  alluded  to,  and  it  is  worth 
while  mentioning  that  a  certain  number  also  develop 
malaise  and  moderate  pyrexia  during  the  succeeding 
twenty-four  to  forty-eight  hours.  This  is  most  often 
the  case  when  pus  is  present,  and  may  be  due  to  auto- 
inoculation. 

During  this  time  a  second  and,  if  necessary,  a  third 
course  of  vaccines  may  be  given,  the  prostatic  massage 
and  irrigations  continuing  until  normal  secretion  only 
is  obtained  from  the  prostate.  After  the  sixth  injection 
no  more  vaccine  is  given  until  ten  days  have  elapsed, 
when  a  second  course  should  be  commenced  if  the  dis- 
charge persist.  The  initial  dose  in  this  course  is  the  same 
as  the  others,  viz.  2  c.c,  and  should  be  given  about  the 
t went}-- fifth  day  of  treatment,  an  interval  of  two  clear 
days  being  allowed  to  elapse  between  subsequent  injec- 
tions. When  both  glasses  in  the  urine-test  are  clear  and 
free  from  filaments,  when  the  prostate  yields  normal 
secretion  on  massage,  and  when  no  discharge  has  been 
visible  for  three  or  four  days  in  spite  of  vigorous  exercise, 
treatment  may  be  stopped  and  the  test-dose  of  vaccine 
given,  as  referred  to  above  in  the  case  of  uncomplicated 
cases.  It  is  believed  that,  by  adhering  to  this  dosage, 
and  particularly  these  intervals,  a  series  of  positive 
phases  is  actually  imposed  successively  one  upon  the 
other,  thus  obtaining  the  maximum  effect  in  the  shortest 
time.  In  practice  it  has  been  found  that  an  increase  in 
the  dose  above  2  c.c.  does  not  improve  the  results,  and 
longer  intervals  are  less  satisfactory.     The  dosage  will 

4 


50     TREATMENT  OF  GONORRHCEA 

vary  slightly  with  different  brands  of  vaccines,  but  this 
can  readily  be  adjusted  by  experience,  whereas  the 
interval  will  probably  be  found  to  be  the  optimum  for 
most  gonococcal  vaccines.  It  is  of  interest  to  note 
that  this  method  of  administering  vaccines  in  large  doses 
at  comparatively  short  intervals  has  given  excellent 
results  in  cases  of  furunculosis  and  impetigo  treated 
with  staphylococcal  cultures,  the  lesions  clearing  up 
with  remarkable  rapidity.  This  method  of  vaccine 
treatment  has  three  advantages : 

(i)  The  speedy  disappearance  of  discharge  and  pain 
on  micturition. 

(2)  Diminished  liability  to   complications. 

(3)  A  sound  test  of  cure.  (Freedom  from  active 
signs.) 

After  four  or  five  days'  treatment  the  discharge  in  an 
acute  case  is,  almost  invariably,  reduced  to  a  bead  in 
the  mornings,  and  the  patient  suffers  little  discomfort 
on  passing  water.  He  realises  that  he  is  getting  better, 
and  it  has  a  marked  effect  on  the  mental  condition. 
The  treatment  of  even  a  few  cases  of  gonorrhoea  soon 
reveals  the  fact  that  despondency  on  the  part  of  the 
patient  is  one  of  the  symptoms  with  which  it  is  hardest 
to  deal,  and  anything  which  tends  to  brighten  his  out- 
look is  of  value.  The  disappearance  of  most  of  the  dis- 
charge after  a  week's  treatment  has  a  remarkably  good 
effect,  and  encourages  the  patient  to  persevere  with  what 
is,  at  best,  an  irksome  daily  routine.  Vaccine  is  of 
undoubted  value  as  a  test  of  cure,  and  should  entirely 
supersede  the  "  Stout  Test."  A  patient  on  the  com- 
pletion of  treatment  is  advised  to  take  no  alcohol  for 
some  months,  since  it  is  often  responsible  for  a  relapse  ; 
and  yet  in  some  instances  he  is  ordered  several  bottles 
of  stout  as  a  "  Test  of  Cure."     It  is  only  natural  for  him 


SPECIAL  TREATMENT  51 

to  repeat  the  test  at  frequent  intervals  for  his  own  satis- 
faction and  so  increase  the  chance  of  a  recurrence. 
With  vaccine  this  is  avoided,  whilst  remaining  just  as 
efficacious,  and  its  use  in  several  thousand  cases  has 
proved  it  to  be  the  most  reliable,  as  well  as  the  most 
practical,  test  apart  from  microscopic  examination. 

Electro-chemical   Treatment   of   Gonorrhoea 

The  electro-chemical  treatment  of  gonorrhoea  dates 
back  many  years,  and,  from  time  to  time,  it  is  revived 
with  some  slight  modification  in  the  method  of  ad- 
ministration. There  is  a  certain  attractiveness  about 
it  which  seems  to  encourage  not  only  the  patient,  but 
the  operator  also.  Just  as  with  the  X-rays,  the  bulk 
of  the  apparatus  as,  for  example,  in  the  polystat  creates 
an  impression,  and  the  very  word  "  Electricity  "  has  a 
magical  effect.  There  is  an  almost  complete  absence 
of  pain  during  treatment,  and  the  discomfort  of  irrigation 
is  avoided.  Unfortunately  the  end-results  of  treatment 
are  not  nearly  so  attractive  as  the  method,  and  for  this 
reason  it  has  been  superseded.  Various  metals  and 
chemical  solutions  have  been  tried  to  get  the  maximum 
destructive  effect  on  the  gonococci,  those  finding  most 
favour  being  salts  of  zinc  or  the  iodides.  In  nearly  all 
recent  work  a  perforated  catheter  has  been  used,  the 
solution  being  run  through  this,  whilst  a  silver  stylet 
conducts  the  current.  It  has  been  pointed  out  pre- 
viously that  gonococci  penetrate  between  the  cells 
and  cannot  be  removed  by  irrigation  alone.  The  object 
aimed  at  in  the  electro-chemical  method  is  to  drive 
active  ions  into  the  mucosa,  and  to  reach  these  organisms. 
It  is  known  that  ions  can  be  made  to  penetrate  the  tissues 
to  considerable  depths  and  there  exert  their  charac- 
teristic actions,  but  when  the  urethral  mucosa  becomes 


52  TREATMENT  OF  GONORRHCEA 

the  surface  within  which  the  active  chemical  agents 
have  to  be  liberated  by  the  passage  of  the  current, 
certain  factors  come  into  play  whose  effects  it  is  difficult 
to  estimate.  Chief  among  these  is  the  presence  and 
circulation  of  the  lymph.  No  sooner  have  the  liberated 
ions  penetrated  the  surface  than  they  meet  with  this 
fluid  of  definite  chemical  composition.  What  reaction 
takes  place  cannot  be  stated,  but  it  is  reasonable  to 
suppose  that  the  free  ions  are  rapidly  fixed  by  various 
substances,  and  their  nascent  effects  soon  lost.  In  other 
words,  before  the  specific  action  of  the  ions  can  be 
exerted  upon  the  organisms  secondary  changes  occur, 
rendering  them  powerless. 

Various  methods  have  been  advocated,  but  practically 
all  are  modifications  of  the  original  apparatus  consisting 
of  a  perforated  catheter,  into  which  fluid  can  be  poured, 
and  a  metal  stylet  inserted  to  conduct  the  current.  The 
following  method,  used  in  a  series  of  cases,  was  found 
quite  convenient  and  the  apparatus  easily  manipulated. 
The  instrument  consisted  of  a  silver-plated  perforated 
catheter,  about  nine  inches  in  length,  enlarged  at  the 
top  into  a  cup-shape  sufficiently  wide  to  accommodate 
an  india-rubber  cork,  through  which  passed  a  hollow 
silver  stylet.  The  stylet  reached  to  within  a  quarter 
of  an  inch  of  the  tip  of  the  catheter,  whilst  the  perfora- 
tions extended  about  five  inches  upwards  from  the  tip. 
A  small  side-tube  was  let  into  the  stem  so  that  fluids 
could  be  run  in  at  will.  A  piece  of  india-rubber  tubing, 
about  one  inch  in  length,  surrounding  the  metal  stem 
about  six  inches  from  the  tip,  secured  a  water-tight  joint 
at  the  meatus  when  the  instrument  was  in  position. 
A  glass  container  and  four  feet  of  rubber  tubing  served 
to  hold  the  chemical  solution.  By  means  of  the  con- 
tainer a  constant  supply  of  fluid  was  assured,  and,  by 


SPECIAL  TREATMENT  53 

raising  it,  the  pressure  in  the  urethra  was  readily 
increased,  thus  distending  the  folds  and  exposing  a 
larger  surface  to  the  action  of  the  ions.  The  solution 
used  was  potassium  iodide,  with  a  little  dissolved  iodine. 
The  catheter  was  sterilised  by  boiling,  and  passed  in  the 
ordinary  way  after  cleansing  the  lips  of  the  meatus, 
care  being  taken  to  adjust  the  ring  of  rubber  so  as  to  fit 
within  the  lips  of  the  meatus  and  prevent  any  leakage 
of  solution.  A  metal  clip,  adjustable  to  any  angle;  was 
attached  to  the  side  of  the  table  and  maintained  the 
apparatus  in  the  correct  position  after  insertion,  the 
patient  lying  at  full  length.  A  large  pad,  consisting  of 
several  layers  of  lint,  was  wrung  out  of  saline  solution 
and  placed  beneath  the  buttock  and  perineum.  To 
this  the  negative  pole  was  connected.  The  catheter 
being  in  position,  the  solution  of  potassium  iodide  was 
run  in  by  opening  the  clip  on  the  supply  tube  from  the 
container.  The  degree  of  pressure  in  each  case  was 
regulated  by  the  patient's  sensation,  the  urethra  being 
kept  comfortably  distended  by  raising  or  lowering  the 
container. 

The  duration  of  the  treatment  on  each  occasion 
was  fifteen  to  twenty  minutes,  the  positive  pole  being 
connected  up  to  the  stylet  within  the  catheter  and  a 
current  of  3-5  milliamperes  passed. 

No  real  pain  was  present  on  any  occasion  during 
administration  of  the  treatment.  But  it  was  frequently 
found  necessary  to  caution  the  patient  about  changing 
his  position,  for  the  least  alteration  in  pressure  on  the 
pad  caused  a  rapid  variation  in  the  current  and,  con- 
sequently, a  slight  shock  to  the  patient.  The  necessary 
current  was  obtained  from  the  main  supply  through  a 
polystat,  and  the  strength  readily  controlled  by  a 
graduated  resistance.    About  five  minutes  was  the  time 


54     TREATMENT  OF  GONORRHOEA 

usually  required  to  reach  5  milliamperes  without  causing 
discomfort. 

The  results  were  distinctly  disappointing,  for  one  case 
only — a  relapse — was  cured  by  this  treatment  alone  and 
all  the  others,  after  reaching  a  muco-purulent  stage,  had 
to  be  given  vaccine  treatment.  Other  solutions,  such 
as  quinine,  calcium  lactate,  etc.,  were  used,  but  with 
no  more  success.  The  impression  formed  on  conclusion 
of  a  full  trial  of  this  method  was,  that  up  to  a  certain 
point  the  electrolysis  had  a  beneficial  effect  on  acute 
urethritis,  but  was  insufficient,  of  itself,  to  lead  to  a 
cure.  The  discharge  diminished  after  several  applica- 
tions, but,  with  the  one  exception  mentioned,  never  dis- 
appeared entirely.  It  would  seem  that  this  method 
might  be  utilized  to  advantage  in  certain  chronic  cases 
where  irrigation  has  been  continued  for  a  long  time 
without  leading  to  a  cure.  The  value  of  a  rest  from 
irrigation  for  some  weeks  is  well  known,  and  during  this 
period  electro-chemical  applications  could  be  applied, 
combined  with  regular  injections  of  vaccine.  There  is 
no  doubt  that  a  beneficial  action  results  from  each 
application,  but  in  the  acute  stage  it  is  not  powerful 
enough,  by  itself,  to  prevent  the  multiplication  of  the 
gonococci.  In  the  chronic  stage,  however,  the  organisms 
are  fewer  in  number,  and  this  form  of  treatment  would  be 
likely  to  have  more  chance  of  success. 

Mercury  Compounds  in  the  Treatment  of 
Gonorrhoea 

From  time  to  time  various  compounds  of  mercury 
have  been  used  with  the  idea  of  cutting  short  the  dura- 
tion of  an  attack  of  gonorrhoea.  Intra-muscular  in- 
j  ection  has  been  found  to  be  the  most  convenient  method 
of  administration,  since  it  allows  a  bigger  dose  to  be  given 


SPECIAL  TREATMENT  55 

than  could  be  tolerated  by  the  mouth  and  occasions  the 
least  disturbance  of  the  digestive  system.  Mercurial 
cream,  salicylate,  and  benzoate  of  mercury,  enesol  and 
many  other  compounds  have  been  tried,  the  usual  dose 
varying  between  50  and  100  milligrammes,  according  to 
the  toxicity  of  the  drug.  The  benzoate  and  salicylate 
have  found  more  favour  than  the  others,  since  their  toxic 
effects,  in  moderate  doses,  are  practically  negligible. 

The  results  of  a  large  number  of  cases  have  been  dis- 
appointing, for  although  there  is  a  speedy  diminution 
in  discharge  on  first  injecting  the  drug,  subsequent 
injections  do  not  lead  to  its  complete  disappearance. 
There  are  cases,  too,  as  described  later  in  connection 
with  gonorrhoea  complicated  by  syphilis,  where  mercury 
seems  to  be  contra-indicated. 

The  usual  methods  of  treatment  are  adopted  as  regards 
medicine  and  irrigation,  and  an  injection  of  mercury 
given  on  the  first  day.  On  the  fourth  day  the  injection 
is  repeated  and  again  on  the  seventh  day,  if  there  are 
no  signs  of  mercurialism.  This  constitutes  a  course, 
and  in  the  ordinary  patient  gives  rise  to  no  ill  effects 
beyond  a  little  tenderness  of  the  gums.  In  very  sus- 
ceptible patients  it  gives  rise  to  diarrhoea  with  the 
passage  of  mucus  and  blood ;  but  vomiting  is  not 
common.  After  a  rest  of  a  week  or  ten  days  a  second 
similar  course  may  be  given,  the  dose  remaining  the 
same,  for  no  benefit  seems  to  accrue  from  increasing  it. 

Clinically  in  an  acute  case  the  first  injection  is  often 
followed  by  a  remarkable  diminution  of  the  discharge 
within  twenty-four  hours,  but  the  later  results  are  not 
so  striking,  the  second  and  third  injections  being  far  less 
potent.  After  treating  some  hundreds  of  cases  on  this 
plan  the  conclusion  arrived  at  was  that  in  a  small  per- 
centage a  disappearance  of  all  discharge  was  obtained 


56     TREATMENT  OF  GONORRHOEA 

in  about  three  weeks,  the  urine  remaining  clear  ;  but  in 
the  majority  no  curtailment  of  the  usual  period  of  treat- 
ment resulted.  The  very  early  acute  cases  seemed  most 
suitable,  but  it  is  just  in  these  that  vaccines  give  such 
good  results.  The  value  of  mercury  is  thereby  minimized. 

Certain  disadvantages  were  also  noticed,  foremost 
among  which  was  the  fact  that,  after  a  course  of  mercury 
injections,  a  case  that  did  not  rapidly  clear  up  often 
became  very  intractable  and  the  injection  of  vaccines 
subsequently  seemed  to  have  much  less  effect  than  usual. 
In  the  case  of  double  infections,  where  the  patient  came 
under  observation  with  a  discharge  only  and  the  sore  had 
not  developed,  the  injection  of  mercury  was  apparently 
responsible  for  a  delay  in  the  appearance  of  the  chancre 
in  some  instances  for  several  weeks.  Complications, 
too,  such  as  epididymitis  and  acute  prostatitis  appeared 
not  infrequently  as  late  as  the  tenth  or  twelfth  week 
of  treatment  without  apparent  cause.  These  disad- 
vantages were  found  to  be  common  to  all  the  mercurial 
preparations  employed,  and  not  to  one  more  than  another, 
whilst  the  results  as  regards  duration  and  relapses  com- 
pare unfavourably  with  those  obtained  from  vaccine 
treatment. 

It  was  hoped  that  the  presence  of  mercury  in  the 
circulation  would  lead  to  destruction  of  the  gonococcus 
in  situ  in  the  various  glands  connected  with  the  urethra, 
thus  overcoming  one  of  the  chief  delays  in  obtaining  a 
cure  ;  but  these  hopes  have  been  sadly  disappointed. 
Exactly  how  far  the  action  of  the  mercury  extends  can- 
not be  stated  precisely,  but  it  falls  far  short  of  the  ideal. 
Many  cases  have  been  seen  in  which  a  patient  ceased 
to  have  a  discharge  for  several  days,  even  when  doing 
hard  work  all  the  time,  and  then  after  about  ten  days 
the  urine  became   hazy  and  a  discharge   reappeared. 


SPECIAL  TREATMENT  57 

The  conclusion  arrived  at  after  watching  a  large  number 
of  cases  throughout  all  stages  of  treatment  and  after 
relapsing,  which  fits  in  most  nearly  with  the  facts 
observed  is,  that  mercury  masks  the  disease  by 
temporarily  diminishing  the  activity  of  the  gonococcus 
without  destroying  it. 


CHAPTER   VII 

COMPLICATIONS   OF    GONORRHOEA 

Epididymitis. — This  is  a  common  complication  of 
gonorrhoea,  and  it  is  quite  impossible  to  say  exactly 
what  determines  its  development.  The  use  of  small 
syringes  and  badly- given  injections  have  been  blamed 
for  a  large  number  of  cases  in  the  past,  but  the  propor- 
tion seems  just  as  large  among  those  who  have  had  no 
treatment  at  all.  A  considerable  number  of  cases 
undoubtedly  follows  after  energetic  treatment  of  the 
prostate,  but  epididymitis  can  also  develop  without  the 
presence  of  signs  of  active  inflammation  in  this  gland, 
though  it  is  unusual.  It  frequently  develops  about  the 
third  or  fourth  week  of  the  disease,  but  in  many  cases 
as  early  as  the  tenth  day.  Its  delayed  appearance 
(tenth  to  twelfth  week)  has  been  referred  to  under  the 
mercurial  treatment  of  gonorrhoea. 
Clinically  four  varieties  may  be  seen  : 

(i)  Hyper-acute  epididymitis. 

(2)  Acute  epididymitis. 

(3)  Sub-acute  epididymitis. 

(4)  Chronic  epididymitis. 

Acute  epididymitis  is  that  most  commonly  seen,  and 
usually  commences  with  pain  in  the  testicle  and  groin 
on  the  affected  side  and  a  slight  rise  in  temperature. 
At  this  stage  a  small  and  extremely  tender  area  can  be 

58 


COMPLICATIONS   OF  GONORRHOEA        59 

felt  at  the  lower  end  of  the  epididymis,  harder  than 
normal  and  but  slightly  enlarged.  Following  on  this 
rapid  swelling  takes  place  and  often  within  twelve  hours 
there  is  a  generalised  enlargement  of  the  epididymis  and 
a  rise  in  temperature  to  103 °  or  higher,  with  severe  pain 
in  the  groin,  described  as  running  up  to  the  kidney  on 
that  side.  The  patient  becomes  unable  to  stand  or  walk 
and  takes  to  bed.  It  has  been  already  mentioned  that 
in  cases  under  observation  and  treatment  the  onset  of 
an  acute  epididymitis  can  often  be  recognized,  shortly 
before  any  swelling  is  perceptible,  by  examination  of 
the  urine,  there  being  a  sudden  change  from  hazy  or 
clear  samples  to  cloudy  ones  which  readily  deposit 
phosphates  on  standing. 

The  hyper-acute  variety  is  not  very  common,  but 
develops  rapidly  and  within  twenty- four  hours  there  is  a 
large  tense  swelling  of  the  epididymis,  frequently  accom- 
panied by  some  orchitis.  It  is  intensely  painful,  the 
skin  of  the  scrotum  being  hot,  red,  and  cedematous, 
while  the  cord  is  tender  on  pressure.  The  patient 
is  flushed  and  may  vomit  at  this  stage.  The  bowels  are 
usually  sluggish  and  the  tongue  coated,  the  temperature 
varying  between  1020  to  1040.  In  this  condition  the 
pain  may  be  so  intense  that  the  patient  loses  all  self- 
control  and  needs  watching  carefully.  Treatment 
must  be  prompt  and  such  as  will  give  speedy  relief. 

The  sub- acute  and  chronic  stages  follow  after  the 
acute,  and  are  but  slightly  painful.  The  temperature 
soon  falls,  and  is  usually  normal  after  three  or  four  days' 
treatment.  The  swelling  at  first  varies  very  little  from 
day  to  day,  but  gradually  softening  commences,  and  the 
testicle  diminishes  in  size.  More  often  than  not  the  cord 
is  the  most  painful,  part  at  this  stage,  and  it  can  be  felt 
as  a  hard  mass  running  up  through  the  abdominal  ring. 


60     TREATMENT  OF  GONORRHCEA 

Under  suitable  treatment  this  soon  subsides,  and  the 
patient  is  able  to  walk  comfortably,  provided  that  a 
suspensory  bandage  be  worn. 

In  the  hyper-acute  variety  one  method  is  pre-emin- 
ently successful,  viz.  puncture  and  aspiration  of  the 
epididymis,  and  seldom  fails  when  properly  carried 
out.  All  that  is  required  is  a  sterile  hypodermic  syringe 
of  i  or  2  c.c.  capacity,  with  a  fine  needle  (preferably 
P.  I.)  fitting  the  glass  barrel  well,  so  as  to  make  an  air- 
tight joint,  and  iodine  for  painting  the  skin.  Prepare 
everything  before  disturbing  the  patient,  and  have  all 
the  materials  within  easy  reach.  Gently  but  firmly  take 
the  affected  testicle  between  the  thumb  and  fingers 
of  the  left  hand,  so  that  the  lower  end  of  the  epididymis 
lies  between  the  thumb  and  index-finger,  the  bulk  of  the 
testicle  resting  on  the  other  fingers.  Paint  with  iodine, 
and,  holding  the  needle  firmly,  push  it  steadily  but  rapidly 
through  the  skin  into  the  epididymis  itself.  Attach 
the  barrel  of  the  syringe  and  draw  out  the  piston. 
Usually  about  i  c.c.  of  blood  or  sero-sanguineous  fluid 
can  be  withdrawn.  The  needle  is  then  removed  and  the 
skin  again  painted  with  iodine.  Should  nothing  be 
withdrawn  the  negative  pressure  is  maintained  in  the 
syringe  and  the  needle  slowly  drawn  out,  when,  usually, 
some  fluid  will  be  obtained.  This  is  of  little  importance^ 
however,  for  the  relief  obtained  bears  little  or  no  rela- 
tion to  the  quantity  of  fluid  withdrawn.  The  use  of  a 
larger  needle  gives  much  more  pain  and  does  not  in  any 
way  assist.  After  the  puncture  a  hot  fomentation  with 
glycerine  and  belladonna  is  applied  and  a  morphia 
suppository,  gr.  J,  given.  Relief  follows  almost  immedi- 
ately and  within  two  or  three  hours  the  pain  is  reduced 
to  a  dull  ache.  Further  treatment  is  then  the  same  as 
described  for  acute  epididymitis. 


COMPLICATIONS   OF  GONORRHOEA        61 

In  acute  epididymitis  the  patient  should  remain  in 
bed,  and  if  already  irrigating  this  must  be  stopped.  The 
affected  testicle  should  be  painted  every  four  hours  with 
glycerine  and  belladonna  followed  by  a  large  hot  fomen- 
tation, one  being  kept  on  until  the  next  is  ready  for 
application.  All  dragging  of  the  testicle  on  the  cord 
must  be  avoided,  and  for  this  purpose  various  forms  of 
support  and  bandages  have  been  recommended.  A 
large  pad  of  cotton- wool,  if  carefully  adjusted,  meets  all 
requirements  and  can  be  readily  renewed  when  soiled. 
An  aperient  is  given  at  the  onset,  and  nothing  compares 
with  calomel  for  this  purpose,  followed  some  hours  later 
by  a  dose  of  white  mixture.  Towards  evening  a  morphia 
suppository,  gr.  J,  is  administered,  and  gives  consider- 
able relief,  besides  assuring  some  hours  of  sleep.  The 
use  of  sodium  salicylate  in  the  acute  stage  is  often 
advocated,  but  it  is  in  no  sense  specific,  and  may  give 
rise  to  vomiting.  When,  however,  the  temperature  con- 
tinues high,  or  when  arthritis  is  present  in  addition,  it 
is  certainly  indicated.  Apart  from  this,  a  simple 
mixture  of  magnesium  salts,  given  two  or  three  times 
a  day,  keeps  the  bowels  acting  regularly  and  is  just 
as  efficacious. 

After  four  or  five  days,  in  favourable  cases,  the  sub- 
acute stage  is  reached,  and  usually  considerable  pain  is 
then  complained  of  in  the  groin  and  cord.  For  this 
ung.  hydrarg.  amnion.,  i  in  4,  is  very  useful,  and 
should  be  rubbed  into  the  groin  on  the  affected  side 
twice  a  day.  This  can  be  done  quite  well  by  the  patient 
himself,  but  should  not  be  continued  for  more  than  three 
or  four  days  at  a  time,  since  the  skin  of  the  groin  tends 
to  become  irritated,  and  may  break  out  in  pustules. 
This  application  speedily  diminishes  the  pain  and 
hastens  resolution.     The  patient  is  kept  on  milk  diet  for 


62     TREATMENT  OF  GONORRHOEA 

three  or  four  days,  when,  if  the  temperature  be  normal 
and  the  pain  subsiding,  a  full  diet  may  be  allowed. 
Vaccines  are  of  proved  value  in  all  the  complications  of 
gonorrhoea,  and  particularly  in  epididymitis.  They 
should  be  given  as  described  under  "  Vaccine  Treat- 
ment/' an  injection  when  the  condition  is  first  diagnosed 
and  then  repeated  on  the  third,  sixth,  ninth  and  so  on 
days.  The  effect  is  especially  seen  in  those  cases  which 
are  slow  in  resolving,  and  where  the  firm  pressure  of  a 
strapping  does  not  seem  sufficient  to  reduce  the  swelling 
to  normal  size.  The  length  of  time  during  which  a 
patient  is  kept  in  bed  depends  entirely  on  the  local 
condition.  In  the  greater  number  of  cases,  after  about  a 
week  or  ten  days,  the  swelling  commences  to  go  down,  all 
pain  disappears,  and  there  is  but  little  tenderness  of 
the  epididymis  on  pressure.  A  strapping  with  Scott's 
dressing  is  then  most  efficacious,  and  after  application 
should  remain  on  for  three  or  four  days.  There  is  a 
tendency  for  the  skin  of  the  scrotum  to  become  inflamed 
around  the  neck  of  the  strapping,  where  there  is  bound 
to  be  some  constriction,  and  a  watch  should  be  kept  on 
this  from  day  to  day.  It  does  not  usually  develop  until 
the  strapping  has  been  in  position  about  three  days. 
When  it  has  occurred  the  strapping  should  be  removed 
at  once,  and  hot  local  baths  substituted  three  times  a 
day.  Another  strapping  can  be  then  applied,  if  con- 
sidered necessary,  when  healing  has  taken  place.  The 
firm  pressure  obtained  by  this  means  leads  to  a  speedy 
return  to  normal  size  and  consistence  in  most  cases. 
The  patient  may  then  be  allowed  up  quite  safely,  but 
should  wear  a  suspensory  bandage  and  walk  about  very 
little  for  some  days. 

Once  the  strapping  has  worked  loose,  a  hot  local  bath 
should  be  commenced  three  times  a  day,  the  testicle  being 


COMPLICATIONS   OF  GONORRHOEA        63 

allowed  to  soak  in  water  just  as  hot  as  can  be  borne 
comfortably  for  ten  or  fifteen  minutes,  and  irrigation 
may  then  be  commenced. 

In  a  certain  proportion  of  cases  as  one  testicle  subsides 
the  other  swells  and  in  these  the  fomentations  must  be 
continued  until  both  testicles  are  subsiding.  In  other 
cases  there  is  a  recurrent  epididymitis,  the  same  testicle 
swelling  up  two  or  three  times.  The  treatment  con- 
tinues the  same,  but  the  possibility  of  a  lesion  in  the 
posterior  urethra  must  be  borne  in  mind.  During  the 
onset  of  acute  epididymitis  all  discharge  frequently 
ceases,  only  to  return  as  the  condition  resolves.  Many 
patients  worry  about  this  return  of  discharge,  which 
they  fondly  imagine  has  gone  for  good,  and  wish  to 
irrigate  at  once.  This  must  be  forbidden,  and  the  only 
safe  guide  for  recommencing  is  the  entire  absence  of 
pain.  When  the  testicle  seems  to  have  reached  a  chronic 
stage  or  is  slow  in  resolving  the  use  of  potassium  iodide, 
grs.  x.  t.d.s.,  together  with  vaccines  as  described,  has 
proved  of  use.  Finally,  it  must  not  be  forgotten  that  in 
a  considerable  number  of  epididymitis  cases  the  prostate 
is  involved,  and  that  this  gland  will  need  further  treat- 
ment. 

Prostatitis  has  been  dealt  with  separately. 

Arthritis  is  a  recognised  complication  of  gonorrhoea 
though  not  nearly  so  common  as  epididymitis.  It  usually 
supervenes  about  the  fourth  or  sixth  week  of  discharge, 
though  occasionally  earlier.  As  in  the  case  of  epididy- 
mitis, it  is  impossible  to  explain  what  determines  its 
onset,  and  a  history  of  recent  injury  is  rarely  volun- 
teered by  the  patient  as  a  cause  for  its  development ; 
but  one  fact  is  of  importance,  viz.  that  arthritis  rarely 
develops  in  an  acute  case  which  has  undergone  adequate 
and  sufficient  treatment  from  the  early  stage  of  the 


64     TREATMENT  OF  GONORRHOEA 

disease.  It  seems  to  occur  most  frequently  in  those 
cases  which  have  neglected  treatment  for  three  or  four 
weeks  after  the  appearance  of  a  discharge,  or  who  have 
been  unfortunate  in  the  treatment  prescribed  for  them. 

In  a  series  of  some  thousands  of  acute  cases  coming 
under  observation  within  two  or  three  weeks  of  the  onset 
not  one  developed  this  complication.  The  joints  most 
frequently  affected  are  the  knees,  then  the  wrists,  ankles, 
elbows  and  hips.  Not  infrequently  the  meta-carpo- 
phalangeal  articulations  are  involved,  while  the  meta- 
tarso-phalangeal  joints  may  be  occasionally,  but  much 
less  frequently  than  the  former. 

Two  types  may  be  recognized : 

(i)  The  inflammation  of  the  joint  is  accompanied  by 
a  considerable  amount  of  effusion,  with  but  little  peri- 
articular infiltration. 

(2)  The  effusion  is  moderate,  but  there  is  much 
infiltration  of  the  peri- articular  structures. 

Any  joint  may  be  affected  with  either  type,  but  the 
first  is  more  frequently  seen  in  the  case  of  the  knee  and 
elbow,  the  second  particularly  in  the  ankle  and  wrist. 

Clinically. — In  the  first  variety  the  onset  is  rapid  and 
commences  with  aching  in  the  affected  joint,  followed 
within  twenty-four  hours  by  considerable  swelling, 
much  pain  on  movement,  and  the  development  of  a 
perceptible  effusion.  The  joint  becomes  hot,  red,  and 
swollen,  and  the  least  movement  causes  pain,  particu- 
larly in  the  case  of  the  knee,  where  walking  becomes 
impossible.  Fluctuation  is  readily  obtained,  and  the 
rapid  onset  of  the  effusion  leads  to  much  distension  of 
the  joint,  one  of  the  most  important  points  to  bear  in 
mind  when  considering  treatment,  upon  the  success  of 
which  depends  its  subsequent  usefulness. 

The  second  type  is  usually  less  rapid  in  onset,  the  joint 


COMPLICATIONS   OF   GONORRHOEA  65 

becoming  slightly  swollen  and  tender,  with  but  little 
effusion.  Movement  of  the  joint  surfaces  upon  one 
another  causes  intense  pain,  as  also  does  the  slightest 
pressure  on  the  joint  itself.  The  swelling  increases  and 
fluid  can  frequently  be  detected,  but  the  surrounding 
structures  of  the  joint  show  the  most  marked  signs,  being 
thickened  and,  at  times,  exhibiting  pitting  on  pressure. 
This  is  best  seen  in  the  ankle  and  wrist,  where  the  extent 
of  the  infiltration  can  readily  be  traced.  Under  suitable 
treatment  the  inflammation  subsides,the  swelling  gradu- 
ally disappears  and  the  fluid  is  absorbed.  The  end- 
results  of  treatment  depend  upon  whether  the  condi- 
tion is  seen  in  an  early  or  late  stage.  An  acute  gonor- 
rhceal  arthritis  seen  within  two  or  three  days  of  its  develop- 
ment and  properly  treated  usually  results  in  the  recovery 
of  full  movement  and  power.  When  seen  later  the 
prognosis  is  not  so  good,  for  there  is  the  probability  of  the 
formation  of  adhesions  and  over- stretching  of  the  joint 
structures. 

Arthritis  seems  to  develop,  in  those  persons  whose 
resistance  to  the  invading  organism  is  below  the  average, 
as  is  shown  by  the  fact  that  many  cases  developing 
arthritis  are  found  to  have  a  severe  urethritis,  prosta- 
titis, with,  frequently,  epididymitis  and  vesiculitis. 
With  improvements  in  the  methods  of  growing  the 
gonococcus  it  will,  possibly,  be  found  that  this  organism 
can  be  recovered  from  the  blood  in  most  cases  of  this  type. 

Treatment. — In  the  acute  stage  the  patient  is  kept  in 
bed,  allowed  milk  diet  with  plenty  of  fluid,  and  given  a 
purge.  Locally  hot  fomentations  with  glycerine  and 
belladonna  are  applied  four-hourly  to  the  joint,  which 
must  be  kept  at  rest.  On  no  account  should  it  be  immo- 
bilized on  a  splint  except  in  the  case  of  the  wrist- joint, 
for  in  all  the  others  the  most  comfortable,  as  well  as  the 

5 


66  TREATMENT   OF   GONORRHOEA 

most  suitable  position  is  obtainable  without  such  appli- 
ances. For  the  elbow,  a  small  soft  pillow  placed  on  the 
affected  side  serves  to  support  and  steady  the  joint, 
leaving  it  free  for  changing  the  dressing  rapidly  and 
without  pain.  For  the  ankle,  a  large  pad  of  wool  and 
two  small  sand-bags  are  quite  sufficient  to  secure  sup- 
port and  comfort,  the  foot  resting  on  its  outer  side 
against  one  bag,  whilst  the  second  supports  the  sole.  The 
slightly  flexed  position  is  best  for  the  knee,  and  is  readily 
obtained  by  placing  a  small  cylindrical  pillow  covered 
with  a  thick  layer  of  wool  beneath  the  joint.  The 
weight  of  the  limb  rapidly  moulds  the  wool  into  the 
right  shape,  and  an  excellent  support  is  obtained.  For 
both  knee  and  ankle  a  cradle  is  essential  to  keep  the 
weight  of  the  bed-clothes  off  the  inflamed  joint.  For 
the  wrist,  a  straight  splint  extending  to  the  tips  of  the 
fingers  is  most  useful. 

Medicines. — Salicylates  are  valuable  in  the  acute  stage 
and  may  be  given  in  various  ways.  In  mixture  form 
sodium  salicylate,  grs.  x.,  combined  with  an  equal 
quantity  of  sodium  bicarbonate,  four-hourly.  In  tablet 
form  aspirin  (grs.  x.  four-hourly)  is  very  satisfactory  in 
relieving  the  inflammation  and  also  in  its  analgesic 
and  soporific  effects.  Some  patients,  though  not  a  large 
proportion,  exhibit  an  idiosyncrasy  to  this  drug,  and  in 
them  it  leads  to  nausea  and  vomiting.  The  best  sub- 
stitute in  these  cases  is  quinine,  which  is  usually  quite 
well  tolerated. 

Aspiration  becomes  necessary  at  times  during  the 
acute  stage  when  the  effusion  is  both  rapid  and  plentiful. 
It  is  a  safe  rule  that  a  tightly  distended  joint  should  be 
aspirated  without  delay  if  the  effusion  has  not  definitely 
diminished  after  twenty-four  hours'  treatment.  To 
wait  longer  is  to  risk  the  subsequent  usefulness  of  the 


COMPLICATIONS   OF  GONORRHOEA         67 

articulation,  especially  in  the  case  of  the  knee,  where  the 
ligaments  are  easily  liable  to  become  overstretched, 
resulting  in  permanent  weakness.  The  greatest  care 
must  be  taken  in  maintaining  asepsis  in  the  perform- 
ance of  aspiration,  for  a  joint  is  readily  infected,  and 
preparation  of  the  skin  is  necessary  exactly  as  for  opera- 
tion. All  the  instruments  must  be  carefully  sterilised, 
a  2  c.c.  syringe  being  most  useful,  with  preferably  a 
P.I.  needle  fitting  the  glass  barrel  accurately.  It  is 
rarely  the  case  that  the  fluid  is  too  thick  to  pass  through 
a  needle  of  this  size.  The  needle  is  pushed  rapidly 
through  the  skin  over  the  selected  area,  and  then  gradu- 
ally made  to  penetrate  the  joint  itself.  Fluid  usually 
begins  to  flow  at  once,  and  the  glass  barrel  may  then  be 
attached,  a  syringeful  at  a  time  being  removed.  The 
removal  of  the  fluid  should  not  be  too  rapid,  since  the 
creation  of  a  sudden  negative-pressure  in  the  interior 
of  the  joint  tends  to  bring  any  loose  flakes  towards  the 
site  of  the  puncture,  and  thus  the  needle  may  become 
obstructed.  Another  point  sometimes  recommended 
is  to  leave  a  little  fluid  in  the  joint,  and  not  to  extract 
the  last  few  c.c.'s,  but  whether  there  is  any  advantage 
to  be  gained  is  not  yet  settled.  After  the  fluid  has  been 
withdrawn  a  hot  fomentation  is  applied  to  the  joint  and 
changed  every  four  hours. 

Vaccines  often  have  a  remarkable  effect  in  the  acute 
stage,  and  are  of  the  greatest  value  in  all  cases.  They 
should  be  given  as  described  under  Vaccine  Treatment, 
the  initial  dose  of  50,000,000  gonococci  when  the  patient 
is  first  seen,  followed  on  the  third  day  by  100,000,000,  and 
repeated  on  the  eighth,  ninth,  twelfth,  and  fifteenth  days. 
There  is  usually  a  marked  improvement  after  the  second 
injection,  the  effusion  commencing  to  subside  and  the 
pain  diminishing  considerably. 


68     TREATMENT  OF  GONORRHOEA 

Sometimes  after  the  first  injection  the  joint  seems  to 
become  more  swollen  in  the  succeeding  twenty-four  hours. 
Aspiration  should  be  performed,  and  the  ordinary  dosage 
continued.  The  effusion  usually  diminishes  then  after 
the  second  injection  and  follows  the  normal  course  ;  but 
in  a  few  cases  aspiration  may  need  to  be  performed 
two  or  three  times. 

When  the  sub-acute  stage  has  been  reached  and  the 
effusion  is  but  slight  the  patient  should  be  encouraged 
to  move  the  joint  a  little  several  times  a  day,  and  it  is 
here  that  the  advantage  of  not  immobilising  it  is  appreci- 
ated, for  there  is  nothing  to  prevent  movement  in  any 
direction.  The  fomentations  should  be  replaced  by 
Scott's  dressing  bandaged  round  the  joint,  and  potas- 
sium iodide,  grs.  x.,  or  more,  given  three  times  a  day 
instead  of  the  salicylate.  Afterwards  massage,  hot 
baths,  and  the  rubbing  in  of  a  stimulating  liniment, 
such  as  lin.  terebinth,  are  needed.  The  latter  can  be 
done  quite  well  by  the  patient  several  times  daily,  especi- 
ally if  there  be  any  pain  or  stiffness  after  exercising  the 
joint. 

Cowperitis. — This  is  not  a  common  complication  of 
gonorrhoea,  but  sufficiently  so  to  need  description,  since 
it  is  of  considerable  interest  from  the  point  of  view  of 
correct  diagnosis  and  suitable  treatment.  Cowper's 
glands,  situated  bi-laterally  close  to  the  anus,  communi- 
cate with  the  urethra  by  two  separate  ducts  opening  on 
the  floor  of  the  bulbous  portion.  They  are  thus  liable 
to  infection,  and  when  this  takes  place  the  symptoms  are 
characteristic.  The  first  is  tenderness  on  pressure, 
probably  noticed  most  when  sitting  down  or  during  an 
action  of  the  bowels,  and  frequently  attributed  by  the 
patient  to  piles  or  the  prostate.  Gradually  the  tender- 
ness increases,  and  from  being  unilateral  may  become 


COMPLICATIONS   OF   GONORRHOEA         69 

bilateral,  though  the  former  is  the  usual.  It  soon  changes 
to  a  constant  aching,  and  acute  pain  is  felt  on  sitting 
down  quickly.  Examination  in  the  early  stage  reveals 
nothing  beyond  slight  pain  on  pressure,  but  after  forty- 
eight  hours  a  little  swelling,  with  reddening  of  the  skin 
over  the  affected  gland,  becomes  perceptible,  and  the  line 
of  one  or  two  lymphatics  may  be  traced.  Under  these 
conditions  a  rectal  examination  should  be  made  at 
once,  and  Cowper's  glands  palpated  between  the  thumb 
and  index-finger,  when  one  gland  is  usually  found  to  be 
small  and  insensitive,  whilst  the  other  is  inflamed  and 
swollen,  hot,  and  exquisitely  tender  on  pressure. 

Treatment. — An  attempt  may  be  made  to  express 
the  contents  of  the  inflamed  gland  as  follows.  The 
urethra  is  irrigated  thoroughly  with  warm  boric  lotion 
until  the  washings  are  clear  and  about  four  ounces  of 
solution  are  left  in  the  bladder.  The  gland  is  then 
massaged  between  the  index-finger  in  the  rectum  and 
the  thumb  on  the  perineum,  the  contents  being  expressed 
through  the  duct  into  the  urethra.  The  patient  then 
empties  his  bladder,  the  boric  lotion  washing  out  any 
secretion  that  has  been  expressed  and  the  presence  of  pus 
thus  readily  detected.  Unfortunately,  however,  the 
duct  in  these  cases  usually  becomes  occluded,  and  nothing 
can  be  expressed.  The  second  method  must  then  be 
adopted  and  is  invariably  satisfactory. 

Large  hot  fomentations  are  applied  to  the  affected 
area  every  four  hours,  and  an  atropine  suppository  given 
at  night  to  relieve  the  tension.  The  following  day  an 
incision  is  made  under  local  or  general  anaesthesia  and 
the  gland  laid  open,  scraped  out  with  a  Volkmann's 
spoon,  packed  with  iodoform  gauze,  and  the  fomenta- 
tions repeated.  Great  relief  follows  at  once,  and  the 
same  evening  a  morphia  suppository,  gr.  J  or  h,  should 


70  TREATMENT  OF   GONORRHOEA 

be  given  to  ensure  comfort  and  sleep.  Subsequently 
healing  takes  place  readily,  and  there  is  no  further 
trouble,  but  in  some  patients  the  organisms  seem  to  lie 
deep  down  in  the  ducts,  and  as  soon  as  healing  has  taken 
place  light  up  a  fresh  inflammation  at  the  same  spot. 
In  these  the  wound  should  be  reopened  and  enlarged, 
the  gland  and  most  of  the  duct  dissected  out,  the  whole 
cavity  scraped  out,  packed  with  iodoform  and  allowed  to 
granulate  up. 

Vesiculitis. — This  is  dealt  with  under  chronic  gonor- 
rhoea. 

Peri-urethral  Abscess. — This  complication  is  the 
result  of  inflammation  of  one  or  more  of  Littre's  glands, 
followed  by  occlusion  of  the  gland  ducts.  Suppuration 
goes  on  within  the  gland,  and  the  inflammatory  products 
are  unable  to  escape,  an  abscess  forming  in  the  ordinary 
way.  In  the  early  stage  a  small  tender  nodule,  about 
the  size  of  a  pea,  can  be  felt  on  palpating  the  urethra. 
It  gives  rise  to  no  pain  apart  from  pressure.  If  untreated 
it  continues  to  enlarge  and  penetrates  deeper  into  the 
submucosa,  causing  a  little  pain  and  marked  tenderness. 
Finally,  if  still  untreated,  it  continues  to  enlarge  and 
eventually  reaches  the  surface,  pointing  beneath  the  skin 
like  an  ordinary  abscess.  Occasionally  the  opposite 
direction  may  be  followed,  and  rupture  into  the  urethra 
occur  spontaneously  ;   but  it  is  unusual. 

Diagnosis  is  quite  simple,  there  being  the  presence  of 
a  discharge  or  a  history  of  a  recent  attack  of  gonorrhoea. 
The  swelling,  when  pointing  beneath  the  skin,  has  all  the 
characteristics  of  an  abscess,  with  tenderness,  swelling, 
and  redness,  whilst  inflamed  lymphatics  can  be  traced 
in  severe  cases,  combined  with  oedema  of  the  penis. 

Treatment. — In  describing  the  routine  method  of 
treatment  the  value  of  the  passage  of  a  straight  metal 


COMPLICATIONS   OF  GONORRHOEA        71 

bougie  about  the  end  of  the  second  week,  and  palpation 
of  the  urethra,  has  been  emphasized.  By  this  means  it 
is  possible  to  discover  any  nodules  which  might  subse- 
quently lead  to  abscess-formation  and  to  express  their 
contents,  for  at  this  period  of  development  they  are 
quite  thin- walled  and  soft. 

In  the  later  stage,  when  a  large  nodule  has  formed, 
the  gland  is  best  incised  through  the  urethroscope  by 
means  of  a  fine-pointed  knife.  The  affected  area  is 
brought  into  view  and,  whilst  the  penis  is  grasped  firmly 
on  the  outside,  the  knife  is  pushed  through  the  mucosa 
towards  the  centre  of  the  abscess.  Pus  may  issue  at 
once,  but  more  often  it  requires  compression  of  the 
nodule  to  express  the  contents  after  the  urethroscopic 
tube  has  been  withdrawn.  The  subsequent  bleeding 
is  never  serious.  This  method  should  be  adopted  in  all 
cases  where  the  abscess  is  not  actually  involving  the  skin, 
and  very  satisfactory  results  can  be  obtained. 

When  it  is  evident  that  extension  has  occurred, 
and  that  the  abscess  is  commencing  to  point  on  the 
exterior,  hot  fomentations  are  applied  every  four  hours. 
Hot  local  baths,  in  which  the  penis  is  allowed  to  soak 
for  ten  or  fifteen  minutes,  are  given  in  between  the  times 
for  the  fomentations,  until  the  abscess  is  ready  for 
incision.  The  incision  should  be  made  at  the  earliest 
possible  moment  and  the  pus  evacuated.  The  longer 
the  abscess  is  allowed  to  spread  the  greater  is  the  risk 
of  a  subsequent  fistula  ;  but,  if  opened  promptly,  it  is 
unusual  for  this  unpleasant  complication  to  develop. 

The  commonest  site  for  these  abscesses  which  reach 
the  surface  is  either  about  two  and  a  half  inches  from 
the  meatus,  or  in  the  region  of  the  bulb.  In  the  latter 
position  care  is  necessary,  after  incision,  to  avoid 
secondary   infection.     After    drainage    these    abscesses 


72     TREATMENT  OF  GONORRHOEA 

usually  heal  readily,  but  treatment  must  not  end  there. 
In  every  case  of  peri-urethral  abscess  there  is  the  risk 
of  a  stricture  developing  later,  and  for  this  reason,  when 
complete  healing  has  taken  place,  a  straight  metal 
bougie  should  be  passed  to  locate  any  narrowing  of  the 
canal.  If  present,  regular  dilatation  will  need  to  be 
carried  out. 

Other  complications  are  inflammation  of  the  various 
fascial  structures,  e.g.  the  plantar  arch,  keratosis, 
endocarditis,  etc.,  but  they  are  not  sufficiently  common 
to  need  description  here. 


CHAPTER    VIII 

GONORRHEAL   CONJUNCTIVITIS 

This  is  a  very  serious  condition,  and  its  importance  and 
the  need  for  thorough  treatment  are  generally  recog- 
nized in  the  case  of  new-born  infants,  where  Crede's 
methods  have  done  so  much  to  improve  matters ;  but 
in  the  case  of  adults  it  is  not  so  widely  realized.  Once 
diagnosed,  a  gonococcal  conjunctivitis  needs  immediate 
and  continuous  attention  if  the  eye  is  to  be  saved  or 
remain  of  value  afterwards,  and  it  is  just  as  important 
and  as  urgent  to  know  and  apply  the  correct  methods 
as  in  dealing,  for  example,  with  post-partum  haemor- 
rhage. The  latter  are  invariably  well  taught,  the  former, 
unfortunately,  but  seldom,  and,  since  perforation  may 
take  place  within  thirty-six  hours  of  onset,  it  is  evident 
that  there  is  no  room  for  delay. 

Infection  does  not  occur  nearly  as  frequently  as  one 
would  expect,  in  spite  of  the  uncleanly  habits  of  many 
gonorrhoea  patients.  The  extension  to  the  eyes  is 
usually  brought  about  by  direct  spread  from  the  fingers, 
handkerchiefs,  or  towels  in  these  cases.  Others,  without 
a  urethritis,  may  become  infected  by  soiled  articles  of 
a  similar  kind  previously  used  by  an  infected  person. 
Whenever  pus  is  present  in  an  eye  a  film  should  be 
made  at  once,  and  examined  as  soon  as  possible  after- 
wards.    The  presence  or  absence  of  a  urethritis  is  no 

73 


74  TREATMENT  OF  GONORRHOEA 

criterion,  though  in  the  former  case  the  probabilities 
are  in  favour  of  the  conjunctivitis  being  gonorrhceal. 

The  smear  is  made  as  follows  : 

A  platinum  loop  is  flamed  and  allowed  to  cool  whilst 
a  glass  slide  is  cleaned  and  dried.  The  patient  sits  down 
in  a  good  light,  the  head  tilted  slightly  backwards.  Two 
small  swabs  of  wool  wrung  out  of  perchloride  of  mercury 
are  placed  over  the  lids,  which  can  then  be  readily 
separated  by  the  index-finger  and  thumb  of  the  left 
hand.  With  the  platinum  loop  a  small  flake  of  pus  is 
removed  from  the  surface  of  the  eye,  transferred  to 
the  slide,  spread  out  in  an  even  film,  and  then  fixed  by 
passing  a  few  times  through  the  flame  of  a  spirit-lamp. 
It  is  stained  by  Gram's  method  and  examined  for  Gram- 
negative  organisms. 

Diagnosis  of  Smear. — -The  typical  film  shows  many 
pus-cells,  with  numerous  intra-cellular  Gram-negative 
diplococci,  a  noticeable  feature  being  the  almost  com- 
plete absence  of  other  organisms.  In  cases  simulating 
gonorrhceal  ophthalmia  clinically  the  slide  usually 
shows  large  numbers  of  Gram-positive  cocci  and  a  few 
Gram-negative  cocci,  frequently  micrococcus  catarr- 
halis.  The  presence  of  a  considerable  number  of 
Gram-positive  cocci  is  against  the  condition  being  one 
of  gonococcal  conjunctivitis. 

Clinical  Features. — -The  two  striking  points  about 
this  condition  are  : 

(i)  The  severity  of  the  inflammation. 
(2)  The  rapidity  of  its  development. 

Thus  a  patient  may  notice  a  small  flake  of  pus  in  the 
eye  in  the  morning  as  the  first  indication  and  be  unable 
to  open  the  eye  six  or  eight  hours  later,  on  account  of 
the  swelling.     The  first  sign  is  often  a  little  irritation 


GONORRHEAL   CONJUNCTIVITIS  75 

under  the  upper  lid,  gradually  increasing  to  a  burning 
sensation,  as  if  a  small  foreign  body  were  lodged  there. 
Rubbing  the  lid  only  increases  the  discomfort,  and  on 
examining  his  eye  the  patient  notices  a  little  yellow  pus 
in  the  corner.  The  irritation  increases  and  tears  are 
freely  secreted,  so  much  so  that  the  eye  has  to  be  kept 
closed.  Pus  continues  to  collect,  the  lids  swell  up,  the 
eye  can  scarcely  be  opened,  and  photophobia  develops. 
Patients  are  seldom  seen  before  this  stage. 

On  examination  the  eye  is  found  to  be  closed  owing 
to  the  swelling  of  the  lids  which  are  red  and  cedematous, 
the  upper  one  being  affected  more  than  the  lower  one. 
Pus  can  frequently  be  seen  exuding  along  the  margin, 
as  well  as  at  the  inner  canthus.  On  separating  the  lids 
chemosis  is  found  to  be  present,  the  palpebral  con- 
junctiva being  tense  and  puffy  with  inflammatory 
secretion.  The  whole  of  the  sclera  is  uniformly  injected 
right  up  to  the  corneal  margin,  and  numerous  flakes  of 
pus  are  present.  The  iris  is  usually  unaffected  at  this 
stage,  and  the  pupil  reacts  normally. 

The  other  eye  may  or  may  not  be  affected,  and  treat- 
ment must  be  modified  accordingly.  A  smear  is  taken 
for  examination,  as  already  described,  and  treatment 
commenced  at  once. 

Treatment. — Once  the  diagnosis  is  confirmed  the 
patient  must  be  told  of  the  risk  of  the  loss  of  sight, 
and  warned  to  carry  out  the  treatment  in  every  detail. 
The  first  point  to  decide  is  whether  both  eyes  are 
affected  or  one  only.  If  the  latter,  every  precaution 
must  be  taken  to  prevent  the  extension  of  the  disease 
to  the  unaffected  eye. 

The  Unaffected  Eye. — The  lids  and  cheek  on  that 
side  are  carefully  washed  over  with  ether  soap  on  a 
gauze  swab,  followed  by  warm  water,  then  dried  and 


76  TREATMENT  OF  GONORRHOEA 

finally  wiped  over  with  a  little  pure  ether.  If  the 
eye  be  kept  firmly  closed  no  smarting  is  caused  by  this. 
A  sterile  watch-glass  of  suitable  size  is  then  fastened 
over  the  eye  and  fixed  in  position  by  means  of  rubber 
adhesive  plaster,  every  care  being  taken  to  secure  the 
portion  which  is  nearest  the  affected  eye. 

If  there  is  the  least  doubt  as  to  whether  the  eye  is 
infected  it  is  wiser  to  leave  it  uncovered  and  treat 
both  eyes  alike. 

The  Affected  Eye. — After  a  smear  has  been  taken  the 
eyelids  are  washed  over  with  a  weak  antiseptic  to  remove 
the  discharge  from  their  margins  and  the  cheek.  A 
pint  of  warm  boric  lotion  in  an  irrigating  can  to  which 
2  or  3  feet  of  india-rubber  tubing  and  a  clip  are  attached 
is  placed  about  2  feet  above  the  patient's  head.  The 
patient  sits  in  a  chair  with  the  head  tilted  slightly 
backwards  and  holds  a  kidney-dish  firmly  in  contact 
with  the  face.  The  lids  are  separated  with  the  index- 
finger  and  thumb  of  one  hand  and  a  jet  of  the  warm 
lotion  played  between  them.  In  a  few  seconds  the 
spasm  of  the  lids  passes  off,  and  they  can  be  fairly 
widely  separated.  The  jet  should  work  repeatedly 
inwards  and  outwards  so  as  to  reach  every  fold  of  the 
conjunctiva,  and,  when  all  pus  has  been  washed  away, 
two  drops  of  i  per  cent,  cocaine  are  placed  in  the  eye. 
A  piece  of  wool  is  then  wrapped  round  a  small  glass  rod 
with  rounded  ends,  or,  failing  this,  an  olive-headed  probe, 
dipped  in  silver  nitrate,  grs.  x.  to  the  ounce,  contained 
in  a  watch-glass  and  applied  to  the  lids  in  the  following 
manner  : 

The  upper  lid  is  first  dealt  with,  being  everted  with 
the  thumb  and  index-finger,  and  the  patient  told  to 
look  downwards.  The  whole  of  the  palpebral  conjunc- 
tiva is  painted  so  as  to  deal  with  every  fold,  special 


GONORRHEAL  CONJUNCTIVITIS  77 

attention  being  paid  to  the  reflection  on  to  the  sclera 
and  the  margin  of  the  lid.  The  patient  is  then  told  to 
look  upwards,  the  upper  lid  replaced  in  the  normal 
position  and  the  lower  one  drawn  down.  This,  too,  is 
similarly  painted  with  the  silver  nitrate.  In  spite  of 
the  local  anaesthetic  this  operation  is  usually  somewhat 
painful  ;  but  a  stronger  solution  of  cocaine  should  not 
be  used  owing  to  the  risk  of  lowering  still  further  the 
resistance  of  the  epithelium.  Any  excess  of  silver 
solution  is  carefully  removed,  and  none  should  be 
allowed  to  come  in  contact  with  the  eyeball.  Two  drops 
of  20  per  cent,  argyrol  are  then  placed  in  the  eye. 
After  half  an  hour  has  elapsed  the  irrigation  with  warm 
boric  lotion  should  be  repeated,  all  pus  washed  away, 
and  two  more  drops  of  argyrol  instilled.  A  dose  of 
gonococcal  vaccine  is  given  at  once,  if  available,  or, 
failing  this,  as  soon  as  possible  afterwards.  The  mixed 
stock  vaccine  already  referred  to  has  given  very  good 
results,  with  an  initial  dose  of  50  million  followed  by  a 
dose  of  100  millions  on  the  third  day.  This  concludes 
the  immediate  treatment,  but  the  subsequent  measures 
are  just  as  important. 

The  patient  must  go  to  bed  at  once,  and  needs  constant 
attention.  Whenever  possible,  someone  specially  trained 
in  the  nursing  of  eye-cases  should  be  obtained.  The 
affected  eye  is  irrigated  every  hour  with  boric  lotion, 
the  lids  being  cleansed  each  time  with  small  pieces  of 
wool.  Two  drops  of  argyrol  are  put  in  every  two  hours, 
I.e.  after  each  alternate  irrigation.  Atropine  is  put  in 
every  four  hours  until  the  pupil  is  well  dilated,  and  no 
covering  is  placed  over  the  eye.  This  treatment  is  con- 
tinued, the  painting  of  the  lids  being  repeated  after 
twelve  hours  and  again  after  a  similar  period  if  con- 
sidered necessary.     The  only  indication  for  reducing  the 


78     TREATMENT  OF  GONORRHCEA 

frequency  of  the  irrigations  is  a  marked  decrease  in  the 
discharge.  When  no  pus  is  present  at  the  end  of  an 
hour  after  irrigation  and  no  flakes  are  washed  away,  the 
number  may  be  reduced  to  one  every  two  hours,  and 
the  argyrol  put  in  every  four  hours.  Atropine  will  then 
be  needed  but  once  a  day.  Under  favourable  circum- 
stances improvement  speedily  takes  place,  and  the  dis- 
charge rapidly  diminishes.  The  swelling  of  the  lids 
becomes  less  marked,  chemosis  decreases,  and  the  injec- 
tion is  less  intense.  The  cornea  remains  clear.  Under 
these  conditions  the  irrigation  may  safely  be  reduced  on 
the  third  or  fourth  day  to  one  every  four  hours  and  the 
drops  of  argyrol  instilled  three  times  a  day.  The  injec- 
tion of  the  conjunctiva  continues  to  diminish,  and  by 
the  end  of  the  week  the  eye  is  normal  again. 

In  later  cases,  in  spite  of  energetic  treatment,  the 
condition  goes  on  to  ulceration  of  the  cornea.  The  other 
signs  remain  the  same,  but  the  cornea  becomes  steamy 
instead  of  remaining  clear,  and  a  beam  of  light  thrown 
on  it  by  means  of  a  convex  lens  shows  an  area  where 
the  epithelium  has  been  destroyed.  At  this  stage  the 
eye  can  be  saved  with  care  and  constant  attention. 
Exactly  the  same  treatment  is  adopted,  only  owing  to 
the  complications  of  corneal  ulceration  healing  takes 
longer.  Atropine,  with  a  drop  of  castor- oil,  should  be 
instilled  every  day,  and  the  vaccines  continued  regularly, 
another  dose  of  ioo  millions  being  given  on  the  sixth 
day  and  again  on  the  ninth,  and  so  on.  Once  the  dis- 
charge has  practically  disappeared  a  change  to  i  in 
4,000  sulphate  of  zinc  as  an  irrigation  for  a  few  days 
is  often  beneficial,  and  hot  fomentations  should  be 
applied  to  the  eye  every  four  hours.  Both  eyes  should 
be  kept  at  rest  as  much  as  possible,  and  no  reading 
permitted    until    healing   is    progressing   satisfactorily. 


GONORRHEAL  CONJUNCTIVITIS  79 

By  means  of  prompt  treatment  many  of  these  cases  can 
be  cured  without  much  disability  resulting,  and  the 
methods  may  be  summarized  as  follows  : 

Immediate  Treatment. 

(1)  Take  a  smear  for  examination  for  gonococci. 

(2)  Cover  the  sound  eye,  if  one  only  affected. 

(3)  Irrigate  the  affected  eye  with  boric  lotion. 

(4)  Paint  the  lids  with  silver  nitrate,  grs.  x.  ad.  one 

ounce. 

(5)  Instil  argyrol  (20  per  cent.). 

(6)  Give  a  dose  of  gonococcal  vaccine. 

(7)  Rest  in  bed,  with  continuous  attendance. 

Continued  Treatment. 

(8)  Irrigate  every  hour  with  boric  lotion. 

(9)  Instil  argyrol  every  two  hours. 
(10)  Repeat  the  atropine  daily. 

It  is  not  proposed  to  deal  here  with  the  metastatic 
conditions  of  the  eye  caused  by  gonococcal  infection, 
since  they  are  not  of  the  same  urgency. 


CHAPTER   IX 

GONORRHOEA   CASES   COMPLICATED   BY   SYPHILIS 

A  certain  proportion  of  cases  of  gonorrhoea  coming 
under  treatment  for  a  discharge  are  found  to  have 
syphilis,  and  vice  versa.  In  view  of  the  fact  that  both 
diseases  have  to  be  treated  concurrently  a  modification 
of  the  methods  ordinarily  adopted  becomes  necessar}', 
and  also  certain  eventualities  need  to  be  watched  for. 
The  ordinary  acute  course  of  the  disease  is  not  altered 
by  the  fact  that  syphilis  is  present,  and  complications 
occur  in  just  the  same  way. 

Balanitis  as  a  complication. — One  of  the  most  unfor- 
tunate conditions  is  the  development  of  balanitis  at  an 
early  stage,  and  neglect  of  treatment  by  the  patient. 
When  advice  is  eventually  sought  it  may  be  quite  im- 
possible to  say  at  once  whether  or  not  gonorrhoea  is 
present.  Another  difficulty  is  that  patients  with  but 
little  urethral  discharge  may  attribute  the  latter  to  the 
sore  on  the  penis.  This  they  try  to  treat  for  them- 
selves, and  so  give  the  gonococcus  a  suitable  opportunity 
of  settling  down  within  the  mucosa. 

Diagnosis. — The  following  conditions  may  be  met  with, 
and  are  divided  into  two  groups,  (a)  and  (b). 

Under  (a)  there  are  cases  where  the  prepuce  can  be 
retracted. 

Under  (b)  there  are  cases  where  the  prepuce  cannot  be 
retracted. 

80 


COMPLICATED   BY   SYPHILIS  81 

Group  (a)  includes  : 

(i)  Balanitis  from  hard  chancre  (and  possibly  soft 
sores),  ?  gonorrhoea. 

(2)  Soft  or  hard  sores,  with  meatal  chancre ;  ?  gonor- 
rhoea. 

Group  (b)  includes  : 

(1)  Sores  palpable  beneath  the  prepuce ;  ?  gonorrhoea. 

(2)  Syphilitic  abrasions  with  phimosis  resulting ; 
?  gonorrhoea. 

In  the  first  group  (a)  there  is  little  difficulty  in  estab- 
lishing the  presence  or  absence  of  gonorrhoea,  all  that 
is  necessary  being  to  thoroughly  cleanse  the  glans  and 
prepuce,  when  on  massaging  the  urethra  a  discharge  is 
at  once  seen,  or  by  means  of  a  two-glass  urine  test  the 
typical  appearances  are  revealed.  In  doubtful  cases, 
when  the  amount  of  discharge  is  very  small,  a  smear 
from  the  meatus  stained  by  Gram's  method  is  con- 
clusive. 

In  the  second  group  (b),  the  delay  in  commencing 
treatment  is  the  troublesome  feature.  The  following 
preliminary  treatment  is  necessary  in  (b)  (1) :  the  penis 
is  bathed  for  ten  or  fifteen  minutes  in  saline  solution, 
as  hot  as  can  be  comfortably  borne,  every  four  hours, 
attempts  being  made  to  retract  the  prepuce  during  the 
process  ;  also  the  prepuce  is  syringed  with  the  same 
solution  by  means  of  a  sterile  glass  syringe  to  remove 
the  accumulated  discharge.  In  many  instances  this  is 
successful  after  forty-eight  hours,  but  in  others  it  may- 
take  several  days. 

In  group  (b)  (2),  syphilitic  abrasions,  this  system  of 
bathing  is  not  effective,  for  considerable  induration  and 
contraction  is  present.  In  some  of  these  cases  it  may 
be  possible  to  retract  the  prepuce  sufficiently  to  introduce 
an  irrigating  nozzle,  when  treatment  can  be  commenced. 
6 


82  TREATMENT  OF  GONORRHOEA 

Failing  this,  circumcision  becomes  necessary,  and  should 
be  performed  after  the  patient  has  had  two  or  three 
injections  of  salvarsan,  the  local  baths  and  syringing 
being  utilised  daily  to  remove  all  discharge  until  the 
operation.  Any  one  of  the  urinary  antiseptics  may  be 
given  during  this  period,  there  being  little  to  choose 
between  them. 

Meatal  Chancre. — This  may  complicate  matters  in 
either  of  two  ways : 

(i)  Irrigation  may  be  found  impossible  until  the 
chancre  has  healed,  owing  to  the  tenderness  on  pressure 
usually  manifested  by  patients  with  these  lesions. 

(2)  Owing  to  the  resulting  induration,  instrumental 
treatment  may  be  impossible  without  a  meatotomy  or 
prolonged  dilatation. 

Little  difficulty  usually  arises  in  diagnosis  in  these 
cases. 

Assuming  that  irrigation  can  be  commenced,  a 
solution  of  1  in  8,000  permanganate  of  potassium  is  used 
and  vaccines  given  on  the  plan  indicated.  A  difficulty 
arises  when  the  vaccine  and  salvarsan  fall  due  on  the 
same  day,  but  in  this  eventuality  it  is  better  to  omit 
the  vaccine,  or  else  give  it  on  the  day  before  the  injec- 
tion of  salvarsan.  The  interval  at  which  the  vaccines 
follow  one  another  is  a  matter  of  considerable  importance, 
and  for  this  reason,  quite  apart  from  any  other  advan- 
tages, the  plan  of  administering  salvarsan  at  weekly 
intervals  by  the  intra-muscular  or  deep  subcutaneous 
method  is  preferable  to  the  intravenous  system,  the 
patient  requiring  fewer  injections.  In  this  way  the 
need  of  postponing  the  vaccines  is  avoided.  As  soon  as 
the  irrigation  is  carried  out  successfully  the  strength  is 
increased  to  1  to  6,000  permanganate. 

The  modern  methods  of  syphilis  treatment  include  a 


COMPLICATED   BY   SYPHILIS  83 

series  of  mercury  injections  during  the  course  of  salvarsan 
administration,  and  on  this  account  the  effects  of  mercury 
on  the  progress  of  the  urethritis  must  not  be  overlooked. 
It  has  been  mentioned,  under  the  treatment  of  gonorrhoea 
by  mercury  compounds,  that  certain  undesirable  effects 
are  often  observed,  such  as  the  late  appearance  of  com- 
plications and  the  intractability  of  some  of  the  cases 
after  the  administration  of  mercury.  By  bearing  these 
facts  in  mind  the  difficulties  can  usually  be  avoided.  The 
conclusion  arrived  at  after  its  prolonged  trial  was  that 
mercury  tends  to  mask  the  disease  by  diminishing  the 
activity  of  the  gonococcus.  For  this  reason  the  treat- 
ment of  the  urethritis  must  be  energetic  from  the  start. 
The  irrigation  is  increased  from  1  in  6,000  to  1  in  4,000, 
if  the  discharge  does  not  speedily  begin  to  clear  up,  and 
vaccines  are  given  from  the  time  of  admission  onwards. 
Mercury  has  a  peculiar  way  of  lighting  up  infection  in 
the  prostate,  as  is  well  shown  by  a  case  quoted  later, 
and  examination  of  this  gland  should  be  carried  out 
about  the  tenth  day  and  its  condition  determined.  The 
passage  of  a  straight  bougie  at  the  end  of  the  second 
week  is  also  useful,  and  plenty  of  exercise  should  be 
taken  each  day.  Complications  must  be  carefully 
watched  for  and  treated  on  the  ordinary  lines. 

In  spite  of  every  precaution,  some  of  these  cases  of 
gonorrhoea  continue  a  discharge  after  completion  of  the 
course  of  salvarsan  without  developing  any  compli- 
cations, and  everything  points  to  mercury  as  the  cause. 
It  raises  the  point  as  to  whether  it  would  not  be  advisable 
to  withhold  the  injection  of  any  mercury  compound  for, 
possibly,  the  first  two  weeks,  when  the  vaccine  would 
have  had  a  very  fair  chance  of  overcoming  the  gonococcal 
infection.  At  present  there  are  no  figures  available  to 
show  what  detrimental  effect  this  plan  would  have  in 


84     TREATMENT  OF  GONORRHOEA 

delaying  the  conversion  of  the  Wassermarm  Reaction 
from  positive  to  negative. 


Cases  with  a  Past  History  of  Gonorrhcea 

A  certain  number  of  cases  of  primary  and  secondary 
syphilis  coming  for  treatment  are  found  to  have  had 
gonorrhoea  in  the  past,  with  or  without  complications,  at 
periods  varying  from  a  few  months  to  many  years. 
Careful  inquiry  should  be  made  as  to  the  occurrence  of 
any  complications  or  subsequent  relapses,  and  the  urine 
tested  for  gonococci,  or,  in  the  absence  of  a  discharge, 
a  smear  made  from  the  prostate.  Many  of  these  patients 
show  no  signs  of  gonorrhcea  and  no  gonococci  can  be 
found,  yet  during  the  course  of  treatment  with  salvarsan 
and  mercury  untoward  symptoms  are  found  to  occur 
in  a  certain  number.  When  this  fact  is  appreciated  the 
cases  are  found  to  be  more  numerous  than  is  usually 
believed,  and  correct  treatment  can  be  applied  at  once. 
The  following  case  is  a  type.  A  patient  was  admitted 
with  primary  syphilis  and  commenced  a  course  of  intra- 
venous injections  of  "  606,"  together  with  mercury 
injections  once  a  week.  At  the  end  of  three  weeks  he 
complained  of  pain  in  the  "  pit  of  the  stomach  "  though 
the  bowels  were  quite  regular  and  the  tongue  clean. 
The  temperature  was  990.  The  pain  continued  in  spite 
of  rest  in  bed  and  later  was  referred  to  the  right  iliac 
fossa,  though  no  definite  tenderness  over  McBurney's 
point  could  be  elicited.  The  temperature  rose  to  10 1°. 
A  history  had  been  obtained,  on  admission,  that  the 
patient  had  ah  attack  of  gonorrhcea  twelve  months 
previously  without  complications,  but  had  seen  no  signs 
of  discharge  ever  since.  A  2-glass  urine-test,  on  admis- 
sion, was  entirely  free  from  filaments,  and  there  was  no 


COMPLICATED    BY   SYPHILIS  85 

discharge  at  any  time.  Owing  to  these  facts  a  digital 
examination  of  the  prostate  was  made,  acute  prostatitis 
diagnosed,  and  thick  yellow  pus  expressed.  Signs  of 
inflammation  were  also  noticed  over  the  site  of  the  left 
Cowper's  gland.  Fomentations  were  applied  to  the 
perineum  for  two  days,  when  pointing  took  place  and 
the  abscess  was  drained  after  incision.  A  smear  was 
taken  from  the  pus  obtained  and  numerous  gonococci 
found.  Arthritis  of  the  left  shoulder  developed  a  week 
later,  but  subsided  under  vaccine  treatment  and  free 
movement  was  subsequently  recovered. 

The  possibility  of  a  re- infection  of  gonorrhoea  was 
negatived  by  the  fact  that  there  was  no  discharge  and 
nothing  in  the  urine  at  any  time  during  the  first  three 
weeks  of  treatment.  The  fact  that  pain  was  referred 
to  the  stomach  in  this  case  tended  to  draw  attention 
away  from  the  actual  site  of  the  trouble,  but  bearing 
in  mind  the  old  history  of  gonorrhoea  a  correct  diagnosis 
was  speedily  arrived  at.  Another  example  with  a 
longer  history  illustrates  the  same  point.  A  patient 
was  admitted  with  primary  syphilis,  and  there  were  no 
signs  of  gonorrhoea.  The  urine  was  normal  on  admis- 
sion, but  there  was  a  history  of  an  attack  four  years 
previously  without  complications.  Twenty-five  days 
after  admission,  when  three  injections  of  mercury  had 
been  given,  acute  epididymitis  developed  without 
apparent  cause.  Trauma  of  any  description  was  not 
accountable  for  it.  The  urine  became  hazy  during  the 
acute  stage,  but  speedily  cleared  up  with  ordinary  treat- 
ment after  the  epididymitis  had  subsided.  The  possi- 
bility of  a  re-infection  whilst  under  treatment  could  be 
definitely  excluded,  and,  in  fact,  the  urethritis  never 
assumed  an  acute  aspect.  The  duration  of  the  epididy- 
mitis  was   three   weeks.     Several   other   similar   cases 


86     TREATMENT  OF  GONORRHCEA 

have  been  noted,  the  commonest  complications  being 
prostatitis  and  epididymitis.  It  is  impossible  to  give 
accurately  the  frequency,  but  5  to  10  per  cent,  were  met 
with  in  one  series  of  syphilis  cases,  with  a  past  history 
of  gonorrhoea.  In  every  syphilis  case  an  inquiry 
should  be  made  as  to  the  occurrence  of  an  attack  of 
gonorrhoea  in  the  past,  the  patient  being  advised  that 
it  is  to  his  advantage  to  admit  it,  and  also  any  compli- 
cations developed  as  a  result  thereof. 

Treatment. — A  two-glass  urine  test  is  made  on  ad- 
mission and  examined  microscopically  for  signs  of 
gonorrhoea,  the  urethra  also  being  inspected  and  inquiry 
made  as  to  the  presence  of  a  gleet  on  rising  in  the  morn- 
ing. The  prostate  is  examined  during  the  first  week 
and  a  smear  made.  If  gonococci  are  found  to  be  pre- 
sent in  this,  irrigation  should  be  commenced,  even  in 
the  absence  of  a  discharge.  By  doing  this  the  likeli- 
hood of  complications  developing  later  is  minimised. 
If  gonococci  are  not  present  no  further  treatment  is 
required.  These  two  examinations  are  well  worth 
carrying  out  systematically,  for  the  development  of 
prostatitis  or  epididymitis  usually  means  a  delay  of  some 
weeks  in  continuing  the  administration  of  salvarsan,  and 
so  defeats  the  object  of  the  intensive  course. 


CHAPTER    X 

CHRONIC    GONORRHOEA 

The  transition  from  the  acute  to  the  chronic  stage  in 
gonorrhoea  is  gradual,  and  there  is,  frequently,  nothing 
in  the  clinical  phenomena  beyond  the  persistence  of  a 
discharge.  It  is  thus  a  difficult  matter  to  say  at  any 
one  period  when  a  case  should  cease  to  be  called  acute, 
and  be  classified  as  chronic  This  difficulty,  however, 
does  not  in  any  way  affect  the  methods  of  treatment  and 
what  follows  may  be  assumed  to  apply  to  all  cases  of 
three  months'  duration  and  over,  whether  following  on 
continuous  treatment  or  relapsing  at  some  period  after 
its  completion.  Cases  of  this  nature  are  essentially 
difficult  and  need  much  attention,  and  the  most  careful 
and  thorough  examination,  if  the  result  is  to  be  successful. 
The  usual  history  is  that  of  a  past  attack  of  gonorrhoea 
with  the  subsequent  reappearance  of  a  discharge  some 
weeks,  months,  or  even  years  later,  quite  apart  from 
the  risk  of  re- infection.  Inquiry  should  be  made  on 
the  lines  suggested  earlier  as  to  the  date  of  the  original 
attack,  the  incubation  period,  and  the  duration  and 
nature  of  the  treatment ;  also  as  to  the  occurrence  of 
any  complication.  The  next  step  is  to  make  a  complete 
examination,  beginning  with  the  discharge  obtained  on 
massaging  the  urethra,  noting  whether  it  is  purulent, 
muco-purulent,  or  transparent,   and  making  a  smear 

87 


88  TREATMENT  OF  GONORRHOEA 

from  it.  The  following  method  should  be  adopted: 
The  prepuce  is  retracted,  cleansed  thoroughly  with  small 
swabs  of  wool  moistened  in  an  antiseptic  solution,  the 
lips  of  the  meatus  separated  and  freed  from  discharge. 
The  urethra  is  then  compressed  from  the  bulb  forwards, 
the  lips  of  the  meatus  again  separated  and  a  small  bead 
of  the  discharge  removed  from  the  urethra  on  a  platinum 
loop.  This  is  transferred  to  a  slide,  fixed  and  stained 
by  Gram's  method.  By  this  means  the  organisms  of 
balanitis  are  excluded  together  with  any  other  con- 
tamination which  may  be  present.  Assuming  that 
gonococci  are  found,  it  remains  to  discover  the  source  of 
the  discharge,  which  can  be  done  only  by  a  process  of 
exclusion. 

The  patient  is  instructed  to  pass  urine  into  four  glasses 
on  first  rising  in  the  morning,  if  possible  the  urine  of  six 
or  eight  hours.  This  test  differentiates  fairly  accurately 
between  the  anterior  and  posterior  urethra  as  well  as 
indicating  involvement  of  the  prostate  ;  but  it  is  better, 
when  the  amount  of  discharge  is  small,  to  adopt  the 
following  modification  : 

The  patient,  having  passed  no  urine  for  several  hours, 
irrigates  the  anterior  urethra  thoroughly.  Cold  boric 
lotion  at  a  pressure  of  two  feet  is  used,  since  this  will 
not  penetrate  beyond  the  triangular  ligament.  The 
washings  are  collected  in  Glass  I.  A  soft  rubber  ca- 
theter is  then  passed,  and  the  urine  drawn  off  from 
the  bladder  into  Glass  2.  The  bladder  is  washed 
out  with  boric  lotion  through  the  catheter  until  the 
washings  return  quite  clear  and  eight  ounces  of 
lotion  are  left  therein.  The  patient  passes  about  two 
to  four  ounces  into  Glass  3.  The  prostate  is  then 
massaged,  and  the  remainder  of  the  boric  lotion  passed 
into  Glass  4. 


CHRONIC  GONORRHOEA  89 

Glass  1  represents :  Anterior  urethra. 

,,      2  ,,  Bladder. 

,,3  ,,  Posterior  urethra. 

4  ,,  Prostate. 

The  types  of  filaments  have  already  been  described 
under  the  heading  of  the  urine  test,  such  as  the  comma's 
from  Littre's  glands  or  heavy  muco-purulent  flakes,  and 
with  experience  they  are  readily  distinguished  and  a 
correct  opinion  formed  as  to  their  origin. 

Prostatic  secretion  and  the  changes  it  undergoes  in 
inflammation  of  the  prostate  have  also  been  explained. 
On  a  subsequent  occasion  the  prostate  should  be  mas- 
saged following  on  thorough  irrigation  of  the  whole 
urethra.  The  first  few  drops  of  secretion  are  allowed 
to  escape  into  a  glass  containing  a  little  water,  and 
then  the  next  drop  is  collected  on  a  glass  slide.  This 
is  spread  out  in  an  even  film  dried  over  the  flame  of  a 
spirit-lamp,  stained  with  Gram's  stain  and  examined 
for  gonococci. 

The  methods  of  examination  so  far  described  give 
very  useful  information,  and  from  the  results  it  becomes 
possible  to  say  whether  gonococci  are  present,  whether 
the  anterior  or  posterior  urethra  is  involved,  or  possibly 
both.  The  existence  of  a  chronic  lesion  of  the  prostate 
or  infection  of  the  bladder  is  revealed,  as  well  as 
involvement  of  the  seminal  vesicles.  These  tests, 
however,  are  concerned  chiefly  with  the  location  of  the 
trouble  and  do  not,  to  any  great  extent,  make  clear  the 
nature  of  the  existing  lesions.  To  discover  the  true 
condition  of  the  urethra  the  urethroscope  is  essential, 
and  a  urethroscope  examination  should  invariably  be 
carried  out  before  deciding  finally  on  a  course  of  treat- 
ment. ' 


9o  TREATMENT    OF  GONORRHOEA 

The  urethroscope  is  simply  a  metal  tube,  illuminated 
inside  by  a  small  electric  lamp,  by  means  of  which 
successive  portions  of  the  urethral  surface  may  be 
examined  as  the  tube  is  withdrawn.  Many  different 
patterns  are  now  available,  but  Luy's  is,  perhaps,  the 
simplest  to  begin  with.  It  consists  of  a  metal  handle 
bearing  a  small  lamp  mounted  on  a  fine  metal  stem 
which  is  sufficiently  long  to  reach  to  the  end  of  the 
urethroscopic  tube  without  projecting.  The  examining 
tube  is  cylindrical,  and  has  a  metal  pilot  for  the  purpose 
of  introduction.  It  is  lubricated  and  passed  in  the 
same  way  as  an  ordinary  sound,  the  pilot  withdrawn, 
and  the  excess  of  lubricant  absorbed  with  small  swabs 
of  wool  mounted  on  wooden  or  metal  stems.  The 
handle  is  attached  to  the  tube  by  means  of  a  thumb- 
screw and  the  light  switched  on.  The  circular  area  of 
mucosa  at  the  end  of  the  tube,  known  as  the  "  central 
figure,"  is  brightfy  illuminated  and  pathological  changes 
can  readily  be  seen.  This  pattern  of  instrument,  whilst 
illuminating  the  area  to  be  examined  very  well,  provides 
no  means  of  testing  the  condition  of  the  urethra  at  any 
particular  point  as  regards  infiltration,  the  presence  and 
location  of  which  it  is  so  important  to  recognize  if  treat- 
ment is  to  be  successful.  Wyndham  Powell's  instru- 
ment provides  for  this,  an  attachment  being  made  so 
that  the  urethra  may  be  distended  with  air  at  will.  It 
differs  from  Luy's  pattern  in  having  an  external  source 
of  light,  parallel  rays  being  reflected  down  the  tube  by 
a  small  mirror  contained  in  the  handle.  When  the  tube 
is  in  position  in  the  urethra  with  the  handle  attached 
its  outer  end  is  firmly  closed  by  a  closely- fitting  glass 
window.  This  permits  a  clear  view  of  the  central 
figure  and  yet  allows  air-distension  to  be  carried  out  at 
the  same  time  through  a  valve,  controlled  by  a  tap,  to 


CHRONIC   GONORRHOEA  91 

which  is  attached  an  india-rubber  hand-bellows.  When 
air  is  pumped  in,  the  tap  being  open,  the  central  figure 
can  be  seen  to  roll  back  gradually  as  the  pressure  rises 
until,  when  fully  distended,  it  disappears  altogether, 
the  urethra  assuming  the  appearance  of  a  long  tunnel. 
On  closing  the  tap,  and  so  shutting  off  the  air-pressure, 
the  sides  gradually  collapse  into  the  position  of  rest. 
One  of  the  most  common  changes  in  gonorrhceal  ure- 
thritis is  the  formation  of  local  infiltrations  with  the 
subsequent  development  of  a  stricture  if  not  recognized 
and  suitably  treated.  By  means  of  air-distension  these 
infiltrations  can  be  readily  detected,  since  any  loss  of 
elasticity  results  in  imperfect  dilatation  at  that  point 
when  the  air-pressure  is  raised.  This  flexibility  of  the 
urethra  will  be  referred  to  again  later  in  connection  with 
the  different  classes  of  case  to  be  dealt  with  ;  but  the 
striking  difference  in  flexibility  between  a  normal  and 
an  infiltrated  urethra  under  air  distension  has  only  to 
be  seen  to  be  appreciated.  More  elaborate  instru- 
ments are  made  for  the  purpose  of  examining  the  pos- 
terior urethra  and  neck  of  the  bladder,  but  the  two 
mentioned  give  the  greatest  possible  assistance  in 
diagnosing  most  lesions  of  chronic  gonorrhoea. 

Technique. — Before  examining  a  patient  with  the 
urethroscope  two  factors  have  to  be  considered : 

(1)  The  amount  of  discharge  present. 

(2)  The  calibre  and  condition  of  the  urethra. 

In  the  acute  stage  it  is  always  inadvisable  to  attempt 
urethroscopy  because  of  the  inflamed  state  of  the 
mucous  membrane  and  the  risk  of  spreading  infection 
deeper  down  the  urethra.  In  the  chronic  stage  the  dis- 
charge is  usually  less  abundant,  but  whenever  the 
amount  is  considerable  it  is  wiser  to  defer  the  examina- 


92     TREATMENT  OF  GONORRHOEA 

tion  until  this  has  been  checked  by  a  few  days'  irrigation. 

It  should  be  an  invariable  rule  never  to  attempt  to 
pass  a  urethroscopic  tube  on  a  patient  whose  urethra 
has  not  been  previously  investigated.  Graduated  metal 
sounds  should  be  passed  at  an  earlier  visit  so  as  to  dis- 
cover the  presence  of  any  obstruction  and  also  to  deter- 
mine what  size  of  tube  can  be  used  for  the  actual 
examination.  The  position  of  the  patient  is  usually 
semi-recumbent  when  a  special  table  is  used,  the  feet 
resting  on  adjustable  supports  ;  but,  failing  this,  a  table 
on  which  the  patient  can  lie  full  length  answers  the 
purpose.  The  instruments  being  laid  out  ready  for  use, 
the  prepuce  and  glans  are  washed  over  with  an  anti- 
septic solution,  special  attention  being  paid  to  the  lips 
of  the  meatus.'  A  suitable  tube  with  its  pilot  is  selected, 
lubricated  thoroughly  with  a  sterile  medium  and  intro- 
duced gently  into  the  urethra.  The  lips  of  the  meatus 
should  be  separated  during  this  proceeding  since  they  are 
liable  to  become  inverted  by  the  descent  of  the  tube 
and  obstruct  its  ready  introduction,  in  addition  to 
causing  unnecessary  discomfort.  The  most  convenient 
size  of  tube  for  general  use  is  No.  26,  and  will  be  found 
suitable  for  the  majority  of  cases.  Should  obstruction 
occur  just  inside  the  meatus  a  preliminary  dilatation 
becomes  necessary  with  graduated  metal  dilators  of 
Wyndham  Powell's  pattern,  or  a  smaller  tube  may  be 
tried.  The  tube  being  in  position,  the  pilot  is  gently 
withdrawn,  any  excess  of  lubricant  removed  with  small 
mounted  swabs  and  the  handle  bearing  the  lamp  at- 
tached. The  examination  is  then  commenced,  the  succes- 
sive fields  being  brought  into  view  and  inspected  as  the 
tube  is  slowly  withdrawn.  Two  precautions  are  necessary. 

(1)  To  maintain  the  tube  in  the  long  axis  of  the  penis 
during  the  examination  so  as  to  avoid  distortion. 


CHRONIC  GONORRHOEA  93 

(2)  To  avoid  pushing  the  tube  down  the  urethra  in 
order  to  examine  an  area  which  has  been  passed  since 
the  folds  of  the  mucosa  are  thereby  liable  to  serious 
injury,  even  from  tubes  made  with  a  round  edge.  When 
properly  carried  out  with  care  and  dexterity  the  patient 
should  experience  no  pain  from  start  to  finish,  except, 
perhaps,  a  little  discomfort  during  the  introduction  of 
the  tube.  The  preliminary  investigation  of  the  urethra 
by  sounds  and  attention  to  detail  both  aid  in  achieving 
this  end,  and  it  is  seldom  necessary  to  use  any  local 
anaesthetic.  In  certain  cases,  however,  an  anaesthetic 
has  to  be  given,  it  may  be  for  a  hyper-sensitive  patient 
or  preceding  some  intra-urethral  operation,  such  as 
incision  of  a  lacunar  abscess.  A  choice  has  then  to  be 
made  between  the  various  available  preparations. 
Cocaine  was  at  one  time  much  in  vogue,  but  it  has 
disadvantages  which  are  not  shared  by  other  more 
modern  preparations ;  besides  which,  its  action  con- 
siderably modifies  the  urethroscopic  picture.  i\lypin 
in  a  strength  of  2  per  cent,  is  quite  harmless  and  causes 
no  appreciable  alteration  in  the  appearance  of  the 
mucosa,  whilst  producing  complete  anaesthesia. 

Urethroscopic  Appearances. — To  appreciate  the  patho- 
logical changes  in  a  urethroscopic  picture,  a  thorough 
acquaintance  with  the  normal  appearance  is  essential. 
A  brief  description  is,  therefore,  given,  but  actual  practice 
is  the  only  way  of  acquiring  this  knowledge.  Seeing 
that  the  examination  is  made  during  the  gradual  with- 
drawal of  the  tube,  it  follows  that  the  bulbous  urethra 
is  first  inspected,  then  the  penile,  finishing  up  at  the 
meatus.  The  normal  mucosa  is  smooth,  red,  moist, 
and  glistening,  the  walls  folding  together  beyond  the 
end  of  the  tube  to  form  a  rosette  with  a  central  lumen 
from  which  numerous  folds  together  with  fine  blood- 


94     TREATMENT  OF  GONORRHCEA 

vessels  radiate  towards  the  periphery,  like  the  spokes 
of  a  wheel,  varying  in  number  in  the  different  parts  of 
the  urethra.  Normally  striation  is  well  marked,  and 
the  colour  is  a  fairly  deep  red  in  the  bulb,  a  little  lighter 
in  the  penile  part,  and  quite  pale  in  the  glandular  portion, 
the  depth  of  colour  depending  on  the  vascularity  of  the 
individual  and  the  presence  or  absence  of  inflammation. 

Opening  on  the  surface  of  the  urethra  along  the  whole 
length  from  the  meatus  to  the  membranous  portion  are 
numerous  glands,  the  glands  of  Littre,  chiefly  distri- 
buted along  the  roof  and  sides  of  the  penile  part.  The 
mouths  of  their  tiny  ducts  are  barely  visible  in  the 
normal  condition,  but  become  evident  when  inflamed. 

The  lacunae  of  Morgagni  also  open  along  the  roof  of 
the  penile  urethra,  the  openings  being  larger  than 
those  of  Littre's  gland  ducts  and,  consequently,  more 
readily  seen  in  the  normal  state.  One  in  particular, 
situated  about  2  cm.  from  the  meatus,  is  practically 
constant,  its  free  margin  being  known  as  the  valve  of 
Guerin.  These  lacunae  are  small  pouches  extending 
at  times  to  a  depth  of  several  millimetres,  at  the  bottom 
of  which  the  openings  of  one  or  more  of  the  ducts  of 
Littre's  glands  may  be  found.  Their  suitability  for 
harbouring  gonococci  is  obvious,  and  once  inflammatory 
changes  have  developed  it  becomes  harder  than  ever 
to  dislodge  them. 

The  ducts  of  Cowper's  glands  open  on  the  floor  of  the 
bulbous  urethra,  but  are  not  usually  visible,  except  under 
air-distension,  owing  to  the  numerous  folds  of  the 
mucosa  at  this  part.  At  times  this  opening  takes  the 
form  of  the  letter  V  like  a  large  lacuna,  with  the 
point  towards  the  bladder,  and  may  then  become  a 
source  of  infection,  though  this  is  unusual. 

Pathological  Changes. — In  chronic  gonorrhoea  changes 


CHRONIC  GONORRHOEA  95 

may  be  found  in  any  of  the  places  described,  viz. 
Littre's  glands,  lacunas  of  Morgagni,  or  any  portion 
of  the  mucosa,  all  of  which  can  be  recognized  by  means 
of  the  urethroscope. 

The  mucosa  gradually  becomes  infiltrated  during 
prolonged  inflammation,  and  may  appear  in  places. 

(1)  Dull  and  hyperaemic,  the  surface  having  lost  its 
glistening  appearance  and  the  characteristic  striation 
being  replaced  by  a  uniformly  red  and  inflamed  central 
figure.  The  numerous  folds  of  the  normal  state  no 
longer  exist,  and  three  or  four  coarse  ones  compose  the 
central  figure.  Under  air-distension  the  lack  of  elas- 
ticity is  at  once  seen. 

(2)  Paler  than  normal,  with  small  white  areas  here 
and  there  in  the  wall,  showing  the  development  of 
fibrous  tissue,  and  early  stricture  formation.  The 
folds  of  mucosa  are  few,  and  there  is  a  marked  loss  of 
elasticity. 

(3)  Where  definite  stricture- formation  is  in  progress, 
the  walls  infiltrated  more  or  less  all  round,  the  lumen 
narrowed,  an  entire  absence  of  folds  and  an  anaemic 
mucosa  from  the  absence  of  blood-vessels  in  the  fibrous 
tissues.  Under  air-distension  the  part  of  the  urethra 
anterior  to  the  stricture  dilates  up,  leaving  the  narrowed 
lumen  in  full  view,  unaffected  by  this  degree  of  air- 
pressure. 

All  stages  may  be  experienced  between  (2)  and  (3), 
depending  on  how  far  the  infiltration  and  fibrosis  have 
progressed,  and  various  classifications  defining  soft  and 
hard  infiltrations  have  been  made  by  Oberlander  and 
others  ;  but  it  is  beyond  the  limits  of  this  work  to  deal 
with  them. 

Littre's  glands,  when  infected,  show  different  changes 
according  to  whether  the  duct  remains  patent  or  becomes 


g6  TREATMENT   OF   GONORRHOEA 

occluded.     In   the   former   case   the   appearance   is   as 
follows  :  — 

The  opening  of  the  inflamed  duct  resembles  a  tiny 
papilla  standing  out  slightly  above  the  general  level 
and  usually  surrounded  by  a  small  ring  of  hyperlink 
mucous  membrane.  A  drop  of  pus  may  be  present 
in  the  mouth  of  the  duct,  or  be  expressed  by  gentle 
pressure  with  the  end  of  the  tube.  If  the  duct  become 
occluded  one  of  two  things  may  happen  ;  either  the 
gland  atrophies  or  a  small  cyst  is  formed.  In  the 
latter  event  the  small  cyst  is  visible  through  the 
urethroscope  as  a  tiny  yellow  circular  projection  of  the 
size  of  a  pin's  head,  though  frequently  larger. 

Lacunae  of  Morgagni  are  very  liable  to  infection, 
like  the  glands  of  Littre.  They  become  red  and  in- 
jected, and  their  openings  usually  appear  as  small  V- 
shaped  areas  with  the  broad  ends  towards  the  meatus. 
The  adjacent  mucosa  is  frequently  inflamed  for  a  dis- 
tance of  two  or  three  millimetres. 

These  changes  have  been  described  with  regard  to  the 
individual  structures  of  the  urethra,  but  it  must  not  be 
imagined  that  one  particular  group  is  affected  in  one 
case  and  another  group  in  another;  a  pure  Littritis, 
for  example,  without  any  affection  of  the  lacunar  is 
uncommon,  as  also  infiltration  of  the  mucosa  without 
involvement  of  some  of  the  glands  of  Littre.  One  of 
the  commonest  lesions  found  in  chronic  gonorrhoea  is 
a  soft  infiltration,  where  the  folds  of  the  mucosa  are 
coarse  and  diminished  in  number,  the  elasticity  much 
less  than  normal,  and  the  surface  dull  and  hyperemia 
In  such  cases  it  is  quite  common  to  find  a  group  of 
inflamed  Littre's  glands  close  to  the  infiltrated  area. 

So  far  the  urethroscopic  examination  has  concerned 
only  the  anterior  urethra  as  far  as  the  bulb,  which  can 


CHRONIC  GONORRHOEA  97 

be  inspected  by  means  of  the  ordinary  straight  tube. 
With  longer  tubes  it  is  possible  to  examine  the  posterior 
urethra  and  neck  of  the  bladder.  Usually  these  tubes 
are  made  with  a  short  beak  so  as  to  facilitate  their 
introduction,  an  oval  opening  being  left  at  the  convexity 
for  observation.  By  their  means  the  verumontanum 
and  openings  of  the  prostatic  ducts  can  be  seen,  and 
also  the  presence  of  abnormalities,  such  as  polypi  in 
this  region.  More  complicated  instruments  with  a 
lens-system,  of  a  pattern  similar  to  the  cystoscope,  are 
made  and  permit  of  various  operative  procedures.  Most 
of  them  employ  water  instead  of  air  for  distending  the 
urethra. 

Only  the  commoner  changes,  such  as  are  most  fre- 
quently seen,  have  been  referred  to  here,  and  those 
which  are  of  most  importance  from  the  point  of  view  of 
treatment.  For  more  detailed  information  on  urethro- 
scopic  work  one  of  the  larger  text-books  should  be 
consulted. 

There  is  one  method  of  examination  in  connection 
with  the  urethroscope  which  is  chiefly  of  value  when  the 
clinical  evidence  is  very  slight.  It  consists  in  giving  a 
moderate  dose  (50  to  100  millions)  of  a  gonococcal 
vaccine.  The  patient  is  examined  twenty-four  hours 
to  forty-eight  hours  later,  when,  if  the  disease  be  still 
active,  the  signs  are  much  more  marked. 

The  methods  of  examination  described  may  be  sum- 
marized under  five  headings  : 

(1)  Microscopic. 

(2)  Four-glass  urine  test. 

(3)  Massage  of  the  prostate. 

(4)  Urethroscope  examination. 

(5)  Vaccine  test. 


98  TREATMENT  OF  GONORRHCEA 

With  the  information  gained  by  these  several  exam- 
inations it  becomes  possible  to  assign  a  case  to  one  or 
more  of  the  following  categories  : 

(a)  Anterior  urethritis,  including  infiltrations  soft 
and  hard,  inflammation  of  Littre's  glands  and  the 
lacunae  of  Morgagni. 

(b)  Posterior  urethritis,  including  prostatitis,  vesi- 
culitis, Cowperitis.  Clinically  a  large  number  of  cases 
are  found  to  come  under  the  first  group,  the  only  signs 
being  a  little  irritability  of  the  urethra  on  micturition, 
with  a  small  drop  of  transparent,  glycerine-like  dis- 
charge at  the  meatus  in  the  morning.  After  a  hard 
day's  work  or  a  long  walk  this  may  appear  opaque  or 
yellow  and  slightly  increased  in  amount.  This  often 
brings  the  patient  to  seek  advice.  Following  the  plan 
laid  down,  the  discharge  should  be  examined  for  gono- 
cocci,  a  urine-test  made,  the  prostate  massaged,  and 
then  urethroscopic  examination  carried  out,  the  patient 
having  passed  no  urine  for  some  hours  previously.  On 
passing  the  tube  resistance  is  frequently  met  with  at 
some  point,  and,  subsequently,  an  infiltration  is  found 
to  be  the  cause,  the  folds  of  the  mucosa  being  dimin- 
ished in  number,  the  lumen  narrowed,  and  infected 
Littre's  glands  present  at  several  points.  In  these 
cases  particularly  a  dose  of  vaccine  twenty-four  hours 
before  examination  with  the  urethroscope  makes  the 
lesions  very  much  more  obvious.  To  cure  these  cases 
is  a  matter  of  time  and  patience,  the  one  essential  being 
regular  attendance  on  the  part  of  the  patient  and  con- 
scientious carrying  out  of  instructions. 

The  chief  part  of  the  treatment  of  this  class  of  case 
consists  of  regular  dilatation  by  means  of  Kollmann's 
dilator,  or  a  modification  of  the  four-branched  pattern. 
These  instruments  are  made  in  several  shapes  so  as  to 


CHRONIC  GONORRHOEA  99 

dilate  the  anterior  urethra  as  far  as  the  bulb,  the 
posterior  urethra  alone,  or  anterior  and  posterior  com- 
bined. The  latest  models  have  four  metal  blades 
attached  to  a  central  stem  in  such  a  way  that  they  can 
be  expanded  by  means  of  a  thumb-screw  at  the  top 
of  the  handle,  the  degree  of  expansion  being  registered 
by  a  pointer  on  a  circular  scale.  The  position  and 
mounting  of  the  blades  are  such  that  the  folds  of  mucous 
membrane  cannot  become  caught  between  them,  and 
there  is  no  risk  of  damaging  the  surface.  When  closed 
for  introduction  the  stem  corresponds  to  a  No.  21  or 
22  Wyndham  -Powell  straight  metal  dilator. 

Two  models  are  made  :  (1)  Irrigating  ;  (2)  Non- 
irrigating. 

In  the  irrigating  pattern  there  is  an  inlet  and  outlet 
whereby  solutions  can  be  run  through  the  urethra  during 
the  process  of  dilatation,  whereas  with  the  non-irrigating 
model  there  is  no  provision  for  this  and  it  dilates  only. 
The  irrigating  models  are  unobtainable  at  the  present 
time,  though  preferable  in  many  ways. 

Technique  of  Dilatation. — Three  points  need  bearing 
in  mind  when  dilatation  is  to  be  carried  out  : 

(1)  The  patient  should  irrigate  thoroughly  before  and 
after  the  dilatation. 

(2)  No  local  anesthetic  should  be  given. 

(3)  Dilatation  should  be  gradual. 

The  urethra  is  washed  clear  shortly  beforehand,  a 
suitable  solution  being  protargol  (1  in  4,000).  For  this 
purpose  the  permanganates  of  potassium  and  zinc  are 
best  avoided,  since  their  astringent  properties  render 
the  surface  dry  and  tenacious,  making  the  introduction 
of  the  instrument,  even  when  well  lubricated,  somewhat 
painful.     After  dilatation  this  objection  does  not  hold. 

The  reason  for  giving  no  local  anaesthetic  is  that  the 


ioo  TREATMENT   OF  GONORRHOEA 

operator  depends,  to  a  considerable  extent,  upon  the 
patient's  sensation  to  guide  him  as  to  the  degree  of 
dilatation  permissible  at  each  sitting.  When  the 
urethra  is  tightly  stretched  a  feeling  of  discomfort  is 
present  which  speedily  gives  place  to  acute  pain  if  any 
damage  be  caused  to  the  surface.  To  give  a  local  anaes- 
thetic is  to  abolish  this  safeguard. 

The  rationale  of  dilatation  is  to  overcome,  by  repeated 
stretching,  the  tendency  of  the  fibrous  tissue  formed 
during  the  inflammation  to  contract  and  lead  to  stricture 
formation.  The  need  for  gradual  dilatation  is  obvious 
since  any  solution  of  continuity  causes  new  fibrous 
tissue-formation  at  that  point  and  defeats  the  object 
of  the  treatment.  Besides  its  effect  on  infiltrations  the 
branched-dilator  favourably  influences  lesions  of  Littre's 
glands  and  the  lacunae.  Considerable  tension  is  set  up 
in  the  walls  by  the  tight  stretching  of  the  mucous  mem- 
brane during  dilatation,  and  this  tends  to  compress  and 
empty  the  contents  of  such  glands  or  lacunae  as  are  not 
obstructed.  In  those  with  occluded  gland  ducts  where 
cyst-formation  has  taken  place  regular  and  gradual 
dilatation  leads  to  their  rupture  and  resolution. 

The  patient  lies  comfortably  on  a  couch  during  the 
operation.  All  aseptic  precautions  must  be  taken,  the 
meatus  and  glans  being  cleansed  with  an  antiseptic 
and  the  dilator  itself  boiled.  The  instrument  is  placed 
in  sterile  water  until  ready  for  use,  then  dipped  in  a 
sterile  lubricant,  such  as  liquid  paraffin,  and  passed 
into  the  urethra.  Two  points  need  attention  at  this 
point : 

(i)  See  that  the  blades  are  completely  closed  before 
attempting  introduction. 

(2)  Support  the  instrument,  once  it  is  introduced,  so 
that  the  weight  of  the  handle  does  not  press  the  point 


CHRONIC  GONORRHOEA  101 

into  the  urethral  wall,  and  maintain  its  long  axis  accu- 
rately in  the  axis  of  the  urethra,  allowing  no  rotation. 

Patients,  more  often  than  not,  are  extremely  nervous 
when  any  instrumental  treatment  has  to  be  carried  out, 
and  the  least  shock  will  upset  them.     To  carry  out 
dilatation  successfully,  the  patient's  confidence  has  to  be 
won,  and  to  cause  unnecessary  pain  at  the  first  attempt 
is  to  minimize  one's  chance  of  success.     He  has  to  be 
convinced  that   no  real  pain  is  involved,   and  every 
detail,  therefore,  needs  attention  from  the  start.     Once 
the  instrument  is  in  position,  the  expansion    must  be 
very    gradual,   the  first   turn  of    the  handle    needing 
especial  care,  since  the  numerous  folds  of  the  urethra 
have  to  adapt  themselves  to  the  four  metal  blades.     The 
tension  is  then  increased  slowly,  the  patient's  sensation 
being  the  best  guide  at  the  first  dilatation.     When  the 
walls    are   getting   somewhat    stretched   tenderness   is 
usually  complained  of  at  one  or  more  places,  frequently 
the  site  of  a  soft  infiltration,  and  from  this  point  onwards 
the  turning  of  the  handle  must  be  very  slow  and  careful, 
not  exceeding  one  division  on  the  scale.     The  instru- 
ment is  allowed  to  remain  in  position  for  about  ten 
minutes  when  this  stage  is  reached,  then  unscrewed  and 
withdrawn.     No    bleeding    should    occur     after    this 
operation,  and  it  is  far  better  to  err  on  the  side  of  too 
little,  rather  than  too  much,  dilatation.     The  leverage 
obtainable  by  the  milled-screw  is  considerable,  and  by 
careless  handling  a  great  deal  of  permanent  damage 
may  be  caused  ;    but    with  experience  the  degree  of 
stretching  attained  can  be  readily  recognized  by  the 
resistance  of  the  blades.     The  operation  needs  to  be 
repeated  at  regular  intervals,  and  it  is  rarely  advisable 
to  perform  it  more  often  than  once  in  six  or  seven  days, 
so  as  to  allow  the  mucous  membrane  a  chance  of  settling 


102  TREATMENT   OF  GONORRHOEA 

down.  The  object  aimed  at  is  to  increase  the  amount 
of  dilatation  at  each  operation  by,  roughly,  one  division. 
Thus,  if  34  were  reached  at  the  first  sitting,  35  would 
be  the  aim  of  the  next  one,  and  36  at  the  third. 
In  many  cases  this  can  be  carried  out,  but  not  in  all. 
Thus,  for  example,  if  in  the  case  quoted  above  35  were 
reached  at  the  second  sitting,  and  a  little  bleeding 
were  produced  by  over-stretching,  it  would  be  found 
that  at  the  third  sitting  pain  would  probably  com- 
mence at  34,  or  even  33,  and  36  could  not  be  reached. 
For  a  day  or  two  following  the  dilatation  a  little  dis- 
charge is  to  be  expected  so  long  as  lesions  are  present. 
When  the  irrigating  pattern  instrument  is  used,  pro- 
targol  (1  in  4,000)  or  silver  nitrate  (1  in  10,000  to 
1  in  5,000)  are  suitable  solutions  to  run  through  during 
the  dilatation.  After  three  or  four  sittings  the  urethra 
should  be  examined  again  with  the  urethroscope  to 
see  what  progress  has  been  made.  The  appearance 
of  the  glands  and  any  infiltrations  should  be  noted 
and  recorded  for  reference. 

Other  instrumental  treatment  is  frequently  valuable 
in  cases  of  chronic  gonorrhoea  where  extensive  involve- 
ment of  Littre's  glands  has  taken  place,  and  numerous 
small  nodules  can  be  felt  on  palpating  the  urethra  with 
a  metal  sound  in  position.  The  branched  dilator  makes 
little  impression  on  these  nodules,  and  the  following 
procedure  is  often  efficacious. 

Inject  a  few  c.cs.  of  2  per  cent,  alypin  into  the 
urethra  by  means  of  a  sterile  glass  syringe,  and  allow 
this  to  be  retained  for  about  five  minutes.  Introduce 
a  No.  22  Wyndham- Powell  straight  metal  bougie, 
noting  if  it  is  "  gripped  "  at  any  particular  part  of  the 
urethra.  If  it  pass  readily,  a  No.  23  is  tried,  until  the 
sise  is  found  which  just  fits  tightly  without  causing  any 


CHRONIC  GONORRHGEA  103 

tension.  The  urethra  is  then  massaged  against  this 
sound,  beginning  at  the  bulb  and  working  forwards. 
The  mucous  membrane  is  rolled  between  the  thumb 
and  index-finger  of  the  right  hand,  the  sound  allowing 
the  necessary  pressure  to  be  made,  whilst  the  left  hand 
steadies  the  end  of  the  instrument  and  keeps  it  in 
position.  When  the  peno-scrotal  junction  is  reached, 
the  index-finger  and  middle  finger  support  the  penis, 
whilst  the  thumb  compresses  the  urethral  wall  against 
the  bougie,  expressing  the  contents  of  many  of  the 
glands.  Since  the  glands  are  chiefly  situated  near  the 
roof,  the  thumb  should  work  round  as  far  as  possible 
towards  the  middle  line.  On  completion  of  one  side 
the  position  is  reversed,  and  the  other  side  similarly 
"stripped."  After  successful  manipulation  many  of 
the  nodules  are  found  to  have  disappeared  and,  in  fact, 
they  can  frequently  be  felt  to  disperse  under  the  pressure. 
A  little  bleeding  is  usually  caused,  but  stops  after  irri- 
gation with  weak  permanganate  of  potash,  1  in  8,000. 
Dilatation  with  the  branched  dilator,  if  needed,  can 
usually  be  commenced  after  a  week's  rest. 

Irrigating  Solutions  in  Chronic  Gonorrhoea.— In 
prescribing  an  irrigation  for  any  special  condition  the 
personal  factor  must  be  taken  into  account,  for  the 
same  solution  will  prove  satisfactory  in  some  cases  and 
unsatisfactory  in  others,  even  though  the  lesions  be 
identical.  The  majority  of  patients  tolerate  the  usual 
strengths  of  permanganate  of  potash,  for  example,  quite 
readily,  and  it  gives  excellent  results ;  yet  in  a  small 
minority  the  patients  cannot  use  it,  even  in  a  strength 
of  1  in  8,000,  since  it  leads  to  acute  pain  soon  afterwards, 
lasting  for  several  hours,  considerable  pain  on  micturi- 
tion, and  even  a  little  haemorrhage,  quite  apart  from 
acute  posterior  urethritis,     This  idiosyncrasy  cannot  be 


104  TREATMENT   OF    GONORRHOEA 

detected  beforehand,  and  is  discovered  only  after  a  few 
days'  use  of  the  solution ,  when  the  patient  complains 
of  some  or  all  of  the  symptoms  mentioned,  and  an 
examination  of  the  urine  shows  that  the  discharge  is 
not  diminishing  appreciably  and  that  there  is  an  excess 
of  mucus  present.  For  this  reason  a  patient  should 
always  be  seen  a  few  days  after  commencing  a  course 
of  irrigation,  and  if  any  idiosyncrasy  be  shown  it  is 
advisable  to  try  another  solution  rather  than  to  persist 
with  the  same  one,  since  there  are  several  to  choose 
from,  and  but  little  difference  in  their  therapeutic  value. 
The  three  solutions  which  have  proved  of  real  value 
after  prolonged  tests  in  several  thousand  cases,  both 
acute  and  chronic,  are  : 

(i)  Permanganate  of  potash. 

(2)  Permanganate  of  zinc. 

(3)  Protargol. 

No  doubt  there  are  many  others,  and  in  recent  years 
there  has  been  a  considerable  addition  to  the  lists, 
especially  of  silver  compounds,  but  those  mentioned 
meet  the  requirements  of  most  cases  and  have  the 
advantage  of  being  readily  obtainable.  Once  a  case  of 
chronic  gonorrhoea  has  been  investigated  on  the  lines 
suggested,  the  gonococcus  found,  and  the  site  of  the 
lesions  determined,  an  irrigation  of  permanganate  of 
potash  (1  in  8,000)  should  be  prescribed. 

Whether  the  anterior  or  posterior  urethra  be  involved 
is  no  matter,  for  it  should  be  the  aim  of  the  patient  to 
fill  up  the  bladder  three  or  four  times  at  each  irrigation, 
and  so  flush  out  the  whole  of  the  lower  urinary  tract. 
Where  idiosyncrasy  is  shown  it  is  advisable  to  change 
to  zinc  permanganate  (1  in  8,000)  which  is  usually  well 
tolerated.     Once  the  patient  has  got  into  the  way  of 


CHRONIC   GONORRHOEA  105 

irrigating  properly  and  successfully  gets  the  solution 
into  the  bladder,  the  strength  may  be  increased  to 
1  in  6,000,  at  which  it  should  remain  unless  there  is  a 
definite  indication  for  a  change.  In  lesions  of  the 
posterior  urethra  and  prostate  the  solution  has  been 
found  the  most  useful. 

Zinc  Permanganate  is  particularly  valuable  in  chronic 
cases  in  which  the  glands  of  Littre  are  affected  and 
where  soft  infiltrations  are  present.  The  urine  in 
these  cases  contains  many  filaments  and  under  its 
influence  seems  to  clear  up  quicker  than  with  the  per- 
manganate of  potash.  A  strength  of  1  in  6,000  should 
be  given  at  first  and  increased,  after  a  few  days,  to 
1  in  4,000  if  well  tolerated.  Patients  often  find  it 
easier  to  irrigate  with  this  solution  than  with  the 
potassium  salt,  and  will  succeed  in  getting  it  into  the 
bladder  when  they  have  repeatedly  failed  with  the 
latter.  In  such  cases  it  is  advisable  to  continue  its  use 
until  proficiency  is  attained,  and  then  to  change  back 
to  the  potassium  salt,  if  necessary,  at  a  later  date. 

Protargol  does  not  come  up  to  the  other  two  prepara- 
tions for  general  usefulness,  one  drawback  being  that 
distilled  water  is  needed  for  making  the  solution.  After 
energetic  instrumental  treatment  it  is  useful  to  prescribe 
since  it  has  no  astringent  effect,  whereas  the  perman- 
ganates may  cause  irritation  and  discomfort  at  this 
stage.  Its  use  before  dilatation  with  the  branched 
dilators  has  been  referred  to  earlier,  and  also  its  suita- 
bility as  a  solution  for  running  through  the  irrigating 
patterns  of  these  instruments.  Its  prolonged  use  is 
not  recommended  since  it  is  not  sufficiently  stimulating, 
and  allows  the  mucosa  to  get  into  a  condition  of  stasis, 
where  there  is  no  purulent  discharge  secreted,  but  always 
a  glairy  mucus. 


io6  TREATMENT   OF  GONORRHOEA 

Vesiculitis. — This  proves,  at  times,  a  very  trouble- 
some complication  of  chronic  gonorrhoea,  for,  once 
infection  has  reached  the  seminal  vesicle,  it  is  only  with 
difficulty  that  it  can  be  eradicated.  The  symptoms  are 
but  slight,  and,  in  many  instances,  it  is  the  persistence 
of  a  discharge  which  leads  to  an  examination  and  dis- 
covery of  the  condition.  The  following  method  should 
be  adopted.  About  eight  ounces  of  boric  lotion  are 
injected  into  the  bladder  after  thorough  irrigation  of 
the  whole  urethra,  and  the  position  already  described 
for  prostatic  massage  is  assumed  by  the  patient.  The 
index-finger  is  passed  into  the  rectum  until  it  dominates 
the  prostate  and  is  then  gently  swept  from  above  down- 
wards and  inwards  over  the  seminal  vesicle  on  each 
side.  When  inflamed,  the  vesicle  can  be  readily  felt  as 
a  small  tender  mass  lying  on  each  lateral  lobe  of  the 
prostate.  When  normal,  it  is  difficult  to  distinguish 
from  the  surrounding  tissue. 

The  secretion  is  of  a  greyish  colour  and  quite  viscid, 
but  when  affected  by  gonococcal  infection  it  becomes 
thick  and,  frequently,  purulent.  Massage  of  the 
vesicle  is  a  delicate  operation  and  should  be  carried  out 
in  an  extremely  gentle  manner,  for  unpleasant  sequelae 
may  arise  from  too  vigorous  treatment.  One  symptom 
needs  mention,  viz.  the  presence  of  blood  mixed  with 
the  seminal  fluid  on  emission.  It  is  found  in  cases  of 
vesiculitis,  and,  when  present,  is  diagnostic.  Its  chief 
importance  lies  in  the  fact  that  it  occasions  the  patient 
so  much  anxiety  about  himself.  Other  symptoms  are 
frequency  of  micturition,  pains  in  the  rectum  and  down 
the  thighs,  nocturnal  emissions,  often  associated  with  a 
condition  of  mental  depression,  the  concomitant  of 
prolonged  treatment.  One  other  symptom,  which  must 
be  quite  rare,  has  been  described  by  certain  writers, 


CHRONIC   GONORRHOEA  107 

and  consists  of  pain  along  the  course  of  both  ureters, 
attributed  to  an  effect  of  the  diseased  vesicles  on  the 
ureters  where  they  approach  the  bladder  wall.  In  cer- 
tain cases  obstruction  of  the  ejaculatory  ducts  develops 
as  a  result  of  vesiculitis,  leading  to  painful  ejaculation. 
On  massage  of  the  vesicles  no  secretion  can  be  expressed, 
and  the  condition  shows  no  signs  of  improvement  under 
irrigation.  It  is  a  very  troublesome  complication,  and 
is  best  left  for  the  specialist  to  deal  with.  Posterior 
urethroscopy  needs  to  be  carried  out  to  determine 
the  changes  in  the  verumontanum  and  utriculus,  since 
these  form  a  valuable  guide  as  to  the  state  of  affairs  in 
the  vesicles  themselves. 

Catheterization  of  the  ejaculatory  ducts  or  cauteriza- 
tion of  their  orifices  may  be  necessary,  followed  by 
subsequent  massage  and  irrigation  ;  but  it  is  unneces- 
sary to  describe  here  the  technique  of  this  somewhat 
complicated  procedure. 

Urethroscope  Treatment. — Under  the  heading  of 
"  Dilatation  "  mention  has  been  made  of  the  use  of  the 
urethroscope  in  controlling  the  amount  of  stretching  at 
each  operation  and  revealing  the  progress  of  healing. 
In  some  of  these  cases,  even  after  prolonged  dilatation, 
certain  resistant  areas  remain  practically  unaffected, 
and  the  urethroscope  is  a  valuable  means  of  applying 
local  treatment  directly  under  the  control  of  the  eye. 
It  is  especially  useful  in  cases  of  chronic  anterior  urethritis, 
where  the  soft  infiltrations  have  been  successfully  cured 
by  means  of  repeated  dilatation,  but  in  which  a  certain 
number  of  Littre's  glands,  or  some  of  the  lacunae, 
remain  unaffected.  Their  mouths  are  inflamed  and 
readily  visible,  with  or  without  the  presence  of  a  tiny 
bead  of  discharge.  Such  glands  can  be  brought  into 
the  field  and  dealt  with  in  one  or  more  ways : 


108  TREATMENT  OF  GONORRHOEA 

(a)  By  painting  with  silver  nitrate  (2  per  cent,  or 
stronger)  by  means  of  small  mounted  swabs. 

(b)  By  means  of  silver  nitrate  fused  on  to  the  end  of 
a  platinum-ended  probe  and  inserted  into  the  gland 
orifice. 

(c)  B3'  the  actual  cautery. 

Of  these  three  probably  the  second  one  is  the  best, 
applied  through  the  Wyndam- Powell  urethroscope,  but 
has  not  given  complete  satisfaction.  A  method  whicli 
has  given  very  successful  results  has  recently  been 
devised  by  the  writer.  For  the  purpose  a  fine  platinum- 
ended  cannula  is  needed,  about  7  inches  long,  to  which 
a  small  glass  syringe  can  be  attached.  The  end  of  the 
cannula  is  of  the  same  bore  as  a  fine  hypodermic  needle, 
but  it  is  cut  off  square.  The  urethroscopic  tube  is 
passed  and  the  affected  gland  brought  into  view.  The 
cannula  is  passed  down  the  tube  and  its  point  gently, 
but  firmly,  inserted  into  the  gland  mouth.  The  syringe 
contains  a  solution  of  iodine  in  chloroform  of  a  strength 
of  1  in  30,  and  a  drop  of  this  fluid  is  expressed  into  the 
gland.  The  cannula  is  at  once  withdrawn,  and  any 
excess  of  solution  removed  with  small  mounted  swabs. 
Each  gland  is  dealt  with  in  turn  until  all  have  been 
injected.  When  properly  carried  out  no  pain  results. 
On  the  following  morning  it  is  usual  to  find  a  bead  of 
very  thick  yellowish-brown  discharge  and  slight  tender- 
ness mav  be  noticed  in  one  or  two  indefinite  areas. 
But  no  further  symptoms  occur.  On  examination  a 
week  later  it  is  almost  impossible  to  identify  these  glands 
from  the  normal.  It  should  be  made  quite  clear  that 
treatment  through  the  urethroscope  is  required  only 
when  all  the  routine  methods  have  been  carried  out 
beforehand.  There  is  one  exception  to  this,  which  is 
dealt  with  in  the  chapter  on  the  complications  of  gonor- 


CHRONIC  GONORRHOEA  109 

rhcea,  viz.  the  incision  of  an  abscess  in  a  gland  or  lacuna 
during  the  early  stage  of  its  development  to  avoid 
the  formation  of  a  peri-urethral  abscess.  The  advan- 
tage of  the  air-inflation  urethroscope  over  the  ordinary 
pattern,  such'  as  Luy's,  is  ver}'  marked  in  this  particular 
branch.  The  glands  and  lacunae  are  made  perfectly 
obvious,  and  it  is  quite  a  simple  operation  to  insert  a 
probe,  pointed  with  silver  nitrate,  into  the  mouth  under 
air-distension.  In  the  ordinary  pattern  the  numerous 
folds  of  the  mucosa  tend  to  conceal  the  openings  of  the 
ducts. 


CHAPTER   XI 

THE   GONORRHCEA   PATIENT 

There  are  certain  features  about  gonorrhoea,  as  a 
disease,  which  considerably  modify  the  patient's  aspect 
of  it.  Thus,  in  the  case  of  married  men  attempts  have 
frequently  to  be  made  to  conceal  the  attack,  and  in  the 
unmarried  man,  at  any  rate  of  the  better  class,  every 
effort  has  to  be  made  to  remain  at  work  and  to  keep 
the  nature  of  the  complaint  a  secret.  Such  difficulties 
as  this,  and  the  numerous  predicaments  in  which  the 
patient  finds  himself  from  time  to  time,  all  tend  to  prey 
on  his  mind,  encouraging  an  unsettled  and  unstable 
condition.  He  visits  his  doctor  when  there  is  no 
alternative  but  to  do  so,  and  trusts  that,  by  the  mercy 
of  Providence,  he  has  got  only  a  mild  attack.  His  first 
inquiries  are  not  as  to  the  danger  of  the  disease,  but  the 
duration  ;  not  as  to  precautions  to  be  taken,  but  the 
time  it  will  take  to  cure  ;  not  as  to  the  risk  of  serious 
after-effects,  but  as  to  how  long  he  will  remain  infectious. 
All  these  concern  the  inconvenience  he  may  be  caused, 
and  the  actual  treatment  he  will  need  to  carry  out  takes 
a  distinctly  second  place.  It  is  important  not  to  over- 
look these  facts,  for  otherwise  serious  mistakes  in  the 
method  of  dealing  with  such  cases  will  occur.  Thus, 
for  example,  a  patient  inquiring  at  his  first  visit  as  to 
how  long  he  will  require  treatment  need  not  be  told  of 
the  risk  of  all  the  complications  which  undoubtedly  may 

no 


THE   GONORRHOEA   PATIENT  in 

occur.  Without  in  the  least  minimizing  the  need  for 
regular  and  efficient  treatment,  a  very  hopeful  prognosis 
can  safely  be  given  in  the  ordinary  acute  case. 

It  is  essential  to  keep  the  patient's  outlook  in  view 
at  all  times  and  to  avoid  any  expression  of  opinion 
which  could  possibly  tend  to  discourage  him.  Even- 
tually, of  course,  the  truth  about  the  duration  of 
infectivity  has  to  be  explained,  but  when  the  patient  is 
practically  cured  the  impression  created  will  then  have 
a  far  less  depressing  effect  than  would  be  the  case  at 
the  onset  of  the  attack.  The  surgeon,  on  his  side, 
starts  with  a  handicap,  for  he  cannot,  as  in  the  case  of 
syphilis,  tell  the  patient  almost  to  a  day  how  long  he 
will  need  to  be  under  treatment.  At  present,  there  is 
no  remedy  comparable  with  salvarsan  for  the  treatment 
of  gonorrhoea,  and  the  probable  duration  of  an  attack 
can  be  estimated  only  after  careful  observation  of  the 
progress  made  on  the  methods  adopted.  This  uncer- 
tainty, however,  is  the  concern  of  the  surgeon  alone, 
and  since  he  cannot,  except  in  a  few  instances,  foretell 
the  cases  in  which  complications  will  occur,  the  best 
plan  is  to  inform  the  patient  of  the  usual  duration  of  an 
uncomplicated  case,  warning  him  of  the  risk  run  by 
neglect  of  treatment  or  indulgence  in  alcohol  of  any 
description.  It  must  be  remembered,  too,  that  when 
the  patient  first  seeks  treatment  he  is,  more  often  than 
not,  suffering  from  the  initial  malaise,  pyrexia,  and 
discomfort  of  the  acute  onset.  He  feels  irritable  and 
run  down,  and  often  has  an  intense  dread  of  having 
contracted  syphilis  in  addition  to  gonorrhoea. 

To  do  all  in  one's  power  to  set  his  mind  at  rest  and 
smooth  out  difficulties  as  they  arise  is  just  as  important 
a  part  of  the  treatment  as  the  irrigations  and  injections. 
The  necessary  rest  in  bed  for  a  few  days  often  causes  a 


H2    TREATMENT  OF  GONORRHOEA 

difficulty,  but  this  can  usually  be  overcome,  and  it  is 
well  worth  while  to  enforce  it  because  the  likelihood  of 
complications  developing  is  thereby  considerably  dimin- 
ished. During  the  course  of  treatment  the  same  care 
must  be  exercised,  for  introspection  soon  develops, 
and  the  patient  will  begin  examining  his  urine  for  threads 
and  other  signs  of  disease,  and  even  haunt  the  public 
library  for  medical  works  on  the  subject.  These  cases 
represent  the  extreme  type,  but  it  must  be  remembered 
that  the  majority  are  easily  disheartened  and  constantly 
need  encouragement. 

In  the  past  quack  remedies  have  had  a  considerable 
vogue,  the  patient  supplementing  his  treatment  with 
one  or  more  ;  but  with  new  legislation  in  progress  this 
practice  is  likely  to  be  short-lived. 

An  excellent  instance  of  the  mental  condition  into 
which  a  patient  can  lapse  is  afforded  by  the  following 
case  : 

The  patient  had  an  attack  of  gonorrhoea  following 
on  which  a  gleet  developed.  Though  but  very  slight,  it 
had  occasioned  him  so  much  anxiety  that,  on  the  advice 
of  a  friend,  he  injected  some  pure  carbolic  acid  into  the 
urethra  with  the  object  of  stopping  the  discharge.  The 
result  no  doubt  exceeded  his  expectation,  for  extensive 
sloughing  ensued. 

Certain  warnings  need  to  be  given  at  the  outset :  for 
example,  the  danger  of  infection  of  the  eyes.  It  is 
best  to  explain  that  this  will  not  occur  if  ordinary  care 
and  cleanliness  be  exercised.  Probably  the  commonest 
cause  of  infection  is  the  use  of  handkerchiefs  to  prevent 
soiling  of  the  clothes.  This  practice  should  always  be 
forbidden,  and  a  small  linen  or  cotton  sac  substituted, 
containing  cotton- wool  which  can  be  changed  frequently 
and  burnt.     Towels,  in  the  same  way,  should  be  kept 


THE  GONORRHOEA  PATIENT  113 

free  from  contact  with  the  discharge.  After  irrigation 
the  patient  should  invariably  wash  his  hands  and  wipe 
them  on  a  towel  kept  for  this  purpose  alone.  As  an 
example  of  the  slight  risk  of  infection  where  ordinary 
care  is  taken,  it  may  be  mentioned  that,  out  of  3,000  cases 
of  gonorrhoea,  not  one  developed  conjunctivitis  after 
beginning  treatment. 

Another  warning  is  required  with  reference  to  over- 
exertion in  the  acute  stage.  Once  the  patient  has  got 
up  and  finds  that  the  discharge  has  almost  disappeared, 
he  is  apt  to  imagine  that  he  can  go  about  as  usual  with- 
out risk.  In  many  instances  no  harm  will  result,  but 
in  a  certain  number  it  leads  to  complications,  especially 
epididymitis.  A  moderate  amount  of  exercise  is  bene- 
ficial at  this  stage,  but  fatigue  must  be  avoided. 

Cases  developing  epididymitis  should  be  advised  to 
wear  a  suspensory  bandage  for  a  month  or  six  weeks 
after  the  swelling  has  subsided. 

Patients  will  often  ask  whether  it  is  advisable  to  wear 
a  bandage  during  an  attack  of  gonorrhoea  when  no 
complication  is  present.  It  should  be  explained  that, 
in  uncomplicated  cases,  the  bandage  is  of  doubtful  value, 
but  can  do  no  harm,  the  decision  being  left  to  the 
individual.  A  constant  watch  should  be  kept  in  every 
acute  case  for  the  development  of  syphilis.  Owing  to 
the  longer  incubation-period  of  this  disease,  a  patient 
contracting  a  double  infection  may  have  been  under- 
going gonorrhoea  treatment  for  two  or  three  weeks  before 
the  primary  syphilitic  sore  develops.  A  small  sore 
may  easily  be  overlooked  or  considered  too  trivial  to 
need  treatment.  The  frequent  use  of  permanganate 
irrigations,  too,  makes  the  slighter  lesions  much  less 
obvious  and  tends  to  promote  rapid  healing.  It  is  quite 
unnecessary  to  tell  the  patient  of  this  risk,  unless  he 
8 


ii4  TREATMENT  OF  GONORRHOEA 

should  inquire  about  it,  so  long  as  he  can  be  kept  under 
observation,  it  being  usually  sufficient  to  inspect  the 
glans,  the  prepuce,  and  coronal  sulcus  periodically  and 
to  palpate  the  inguinal  glands  at  the  same  time.  The 
method  of  irrigation  has  been  dealt  with  under  "  Routine 
Treatment,"  and  any  difficulties  connected  with  it  are 
best  overcome  by  demonstration.  The  use  of  a  glass 
syringe  in  place  of  the  irrigating-can  and  nozzle  should 
not  be  allowed,  since  it  is  inferior  in  every  way,  and  leads 
to  complications  if  carelessly  handled. 

The  remaining  question — the  test  of  cure — is  dealt 
with  separately,  since  it  involves  a  consideration  of 
various  details  and  methods  described  later. 

Test  of  Cure 

The  Complement-fixation  test  which  is  so  valuable  in 
syphilis  has  not  3^et  reached  a  practicable  stage  in  the 
case  of  gonorrhoea,  and,  consequently,  it  is  not  so  simple 
a  matter  to  pronounce  a  patient  to  be  cured.  In  the 
past  and,  in  many  instances,  at  present  even  the  "  Stout 
Test  "  is  considered  sufficient.  The  patient  drinks 
several  bottles  of  stout  and  his  urine  is  examined  for 
signs  of  a  discharge.  Failing  an  obvious  relapse,  he  is 
sent  away  after  a  further  short  period  of  observation. 
Under  vaccine  treatment  this  test  has  been  denounced 
because  it  defeats  the  aim  of  treatment,  the  patient  taking 
alcohol  although  its  effects  are  known  to  be  detrimental. 
On  completion  of  a  course  of  treatment  the  value  of 
vaccines  as  a  test  of  cure  has  already  been  sufficiently 
emphasized.  Assuming  that  the  patient  shows  no  sign 
of  relapse,  he  should  be  advised  to  have  an  examination 
made  again  in  three  months'  time.     This  should  include  : 

(i)  Examination  of  a  two-glass  urine  test,  the  urine 


THE  GONORRHOEA   PATIENT  115 

to  be  a  6  or  8  hours'  specimen,  passed  twenty- four 
hours  after  receiving  a  dose  of  gonococcal  vaccine  (100 
million  gonococci). 

(2)  Massage  of  the  prostate,  a  smear  being  taken  for 
microscopic  examination. 

(3)  Urethroscopic  examination. 

The  urine  may  contain  a  few  threads.  If  this  be  the 
case,  they  should  be  taken  up  with  a  fine  glass  pipette 
and  transferred  to  a  slide,  teased  out,  stained  by  Gram's 
method,  and  examined  for  gonococci. 

The  character  of  the  prostatic  secretion  will  reveal 
gross  lesions  of  the  prostate  and  microscopic  examina- 
tion of  the  slide  supplements  this. 

Urethroscopic  examination  is  the  most  important  of 
all,  and  without  its  aid  no  final  pronouncement  of  cure 
is  justifiable,  even  though  the  microscopic  examination 
reveal  no  gonococci.  Certain  points  need  particular 
attention  in  these  cases.     Briefly  they  are  : 

(1)  The  colour  and  brilliance  of  the  mucosa.  The 
mucosa  should  be  of  uniform  colour  throughout,  corre- 
sponding, of  course,  with  each  particular  region,  showing 
no  hypersemic  areas,  and  combined  with  a  glistening 
appearance  which  readily  reflects  light  from  every  point. 
In  other  words,  a  normal  central  figure. 

(2)  Folds. — These  should  be  numerous  and  well 
formed,  not  thick  and  coarse,  responding  freely  to  air- 
dilatation  with  the  urethroscope. 

(3)  The  vascular  striation  should  be  visible  as  in  a 
normal  urethra,  but  this  condition  cannot  always  be 
fulfilled. 

(4)  Glands  of  Littre  and  Lacunae. — These  should  show 
no  sign  of  inflammation  round  the  gland  mouths.  The 
openings  of  the  gland  ducts  should  be  barely  visible, 
and  of  the  same  depth  of  colour  as  the  surrounding 


ii6  TREATMENT  OF  GONORRHCEA 

mucosa.  No  cysts  should  be  present.  This  examina- 
tion is  a  complete  one,  and,  if  it  give  negative  results  in 
all  three  sections,  the  patient  is  probably  cured,  though 
a  second  examination  after  a  further  interval  (two  to 
three  months)  is  preferable  before  giving  the  final  pro- 
nouncement. After  another  three  months,  i.e.  six  months 
after  completion  of  treatment,  the  examination  should 
be  repeated  in  entirety,  when,  if  all  three  methods  again 
prove  negative,  the  patient  can  be  considered  cured 


INDEX 


Abscess,  peri-urethral,  70 

Of  prostate,  26 
Adenitis  of  groins,  8 
Anaesthetic,  local  for  urethra,  102 
Appearance     of     urethra     with 

urethroscope,  93 
Arthritis,  gonorrhoeal,  63 
Aspiration  of  joints  in  arthritis,  66 
Atropine   suppository,    preceding 

prostatic  massage,  33 


Balanitis     complicating       gonor- 
rhoea, 81 
Baths  in  prostatitis,  28,  33 
Bougies  in  anterior  urethritis,  43 
Prostatitis,  34 
Clutton's,  34 


Case-recording,  method  of,  5 
Chancre,  meatal,  82 
Conjunctivitis,  treatment  of   75 

Diagnosis  of,  74 

Appearance  of  smear  in,  74 
Cowperitis,  68 
Cure,  test  of,  114 


Depression    in      chronic     gonor- 
rhoea, 106,  112 

Diet  in  acute  stage,  38 

Dilatation,  method  of,  99 
Irrigating  solutions  in,  102 
Precautions  necessary,  101 

Dilator,  Kallmann's  anterior,  99 
Posterior,   35 


Electro-chemical  treatment,  51 
Enlargement  of  glands  in  groin,  8 
Epididymis,  puncture  of,  60 
Epididymitis,  58 
Examination  of  Cowper's  glands, 

69 
Of  urine,  15 
Patient,  method,  7 
Prostate,  25 
Urethroscopic,  91 
Vesicles,  106 
Exercise  in  acute  stage,  39 

Fainting    after    examination    of 

prostate,  26 
Folliculitis,  peri-urethral,  70 


Gonorrhoea,  complications  of,  58 
History,  diagnosis,  etc.,  5 
Routine  treatment  of,  38 

Gonorrhoeal  arthritis,  63 
Conjunctivitis, 
Epididymitis,  58 
Prostatitis,  23 

Groin,  enlarged  glands  in,  8 

Haemorrhagic  Urethritis,  4 
Hip-baths  in  prostatitis,  28,  33 
Hypospadias,   special  nozzle   for 
irrigation,  41 

Incision  of  peri-uretbral  abscess, 

71 
Indications    for    examination    of 
prostate,  24 


117 


n8 


INDEX 


Infiltration  of  urethra,  91,  95 
Ionisation  of  urethra,  51 
Irrigation,  method  of,  41 
Solutions  for,  104 


Janet's  system  of  irrigation,  41 


Kollmann's    Dilator,    method    of 
use,  99 
Straight  Dilator,  99 
Posterior  Dilator,  35 


Lacuna?  of  Morgagni,  96 
Littritis,  95 

Local  anaesthetic,  for  bougies,  102 
Baths  in  epididymitis,  62 


Massage  of  Littre's  glands,  43,  103 

Prostate,  25,  33 
Meatal  chancre,  82 
Medicines  in  acute  stage,  39 

Arthritis,  66 
Mercury  compounds,  use  of,  54 


Normal  appearance  of  urethra,  93 


Operation    for   peri-urethral   ab- 
scess,   urethroscopic,    71 


Palpation  of  Littre's  glands,  43, 

103 
Peri-urethral  abscess,  70 
Permanganate    of    potassium,    as 
an  irrigating-solution,   104 
Of  zinc,  as  an  irrigating-solu- 
tion, 105 
Prostate,  massage  of,  25,  33 
Prostatitis,  Acute,  diagnosis  of,  28 
Use  of  bougies  in,  34 
Chronic,  31 


Protargol  for  irrigations,  105 
Puncture  of  epididymis,  60 
Pyrexia  after  massage  of  prostate 
49 


Recording  cases,  5 
Urine-test,  19,  21 


Secretion  in  prostatitis,  26 
Smear  from  eye,  74 
Prostatic,  13 
Urethral,  12 
Solutions  for  ionisation,  51,  54 

Irrigating,  104 
Sounds,    metal,   in   anterior   ure- 
thritis, 43 
Prostatitis,  34 
Suppository,    preceding    massage 

of  prostate,  33 
Symptoms  of  prostatitis,  24,  27, 

3i 
Syphilis  complicating  gonorrhoea, 
80 

Temperature    of   irrigating    solu- 
tions, 40 
Test  of  cure,  114 
"Test"  Vaccine,  50 
Threads  in  urine,  19,  20 
Treatment,  electro-chemical,  51 

Mercury,  54 

Urethroscopic,  107 

Vaccine,  44 


Urethral  chancre,  7 
Urethroscope,  Luy's,  90 

In  peri-urethral  abscess,  71 

Use  of,  91 

Wyndham- Powell's,   91 
Urethroscopic  appearances,  93 
Urine,  examination  of,  15 

Filaments  in,  19 

For  gonococci,  13 

Recording,  19,  21 


INDEX 


119 


Vaccine  test,  50 

Vaccines,  in  acute  stage,  44 

Arthritis,  67 

Chronic  prostatitis,  35 

Dosage  of,  46 

Epididymitis,   62 

Positive  phase,*  45 


Vesiculitis,  treatment  and  symp- 
toms, 106 

Wyndham- Powell's    bougies,    43, 
102 


Zinc,     permanganate, 
gating,  104 


for     irri- 


H.  K.  LEWIS  AND  COt  LTD] 

136  GOWER  STREET,  LONDON,  W.CI 

AND  PRINTED  BY  HAZELL,  WATSON  AND  VTNEY,  tl> 

LONDON  AND  AYLESBURY. 


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